Hypertension in Patients Receiving Maintenance Hemodialysis: Beyond Sodium and Dry Weight

Hypertension is highly prevalent in patients receiving maintenance hemodialysis and is strongly associated with adverse cardiovascular outcomes. Optimal strategies for diagnosis and management of hypertension are uncertain. Peridialysis blood pressure (BP) measurements, although critical for safety monitoring, are increasingly recognized as being unreliable for diagnosing hypertension or guiding therapy. Current evidence supports the use of 44-h ambulatory BP monitoring as the preferred diagnostic method, with home BP monitoring as a practical alternative. Out-of-office measurements correlate more closely with cardiovascular outcomes, left ventricular hypertrophy, and mortality than peridialysis readings. Despite observational data suggesting a linear association between higher out-of-dialysis BP and adverse outcomes, randomized controlled trials establishing definitive BP targets in dialysis patients are lacking. Both extremes of BP may confer harm, and aggressive BP lowering increases the risk of intradialytic hypotension and vascular access complications. Management should prioritize the optimization of volume status by attainment of dry weight and sodium restriction. If BP remains high, pharmacotherapy is indicated. Beta-blockers are generally favored as first-line agents given their antihypertensive efficacy and potential cardiovascular benefits. Future research should focus on the role of emerging cardiovascular therapies, large-scale clinical trials to establish appropriate BP targets, and real-world implementation of out-of-office BP measurements.