Blood pressure targets and pharmacotherapy for hypertensive patients on hemodialysis

ABSTRACT

Introduction

Hypertension is highly prevalent in patients with end-stage kidney disease on hemodialysis and is often not well controlled. Blood pressure (BP) levels before and after hemodialysis have a U-shaped relationship with cardiovascular and all-cause mortality. Although antihypertensive drugs are recommended for patients in whom BP cannot be controlled appropriately by non-pharmacological interventions, large-scale randomized controlled clinical trials are lacking.

Areas covered

The authors review the pharmacotherapy used in hypertensive patients on dialysis, primarily focusing on reports published since 2000. An electronic search of MEDLINE was conducted using relevant key search terms, including ‘hypertension’, ‘pharmacotherapy’, ‘dialysis’, ‘kidney disease’, and ‘antihypertensive drug’. Systematic and narrative reviews and original investigations were retrieved in our research.

Expert opinion

When a drug is administered to patients on dialysis, the comorbidities and characteristics of each drug, including its dialyzability, should be considered. Pharmacological lowering of BP in hypertensive patients on hemodialysis is associated with improvements in mortality. β-blockers should be considered first-line agents and calcium channel blockers as second-line therapy. Renin-angiotensin-aldosterone system inhibitors have not shown superiority to other antihypertensive drugs for patients on hemodialysis.

KEYWORDS:

• Antihypertensive agents
• cardiovascular disease
• end-stage kidney disease
• hemodialysis
• hypertension
• pharmacotherapy

Article highlights

• Hypertension is highly prevalent in patients on dialysis. Peri-dialytic blood pressure (BP) measurements (i.e., immediately before, during, and after hemodialysis) are not reliable estimates of actual BP. Therefore, precise assessment and management of hypertension should be based on out-of-dialysis BP measurements, including home BP and ambulatory BP monitoring (ABPM).

• Hypertension diagnosed by out-of-dialysis measurements at home or with ABPM appears to be a risk factor for cardiovascular mortality. Hypertension is defined as ≥135/85 mmHg on home BP monitoring or 44-h ABPM over the dialysis interval.

• Nonpharmacological interventions that target excess sodium and volume are essential for management of hypertension. Pharmacotherapy is required when hypertension remains uncontrolled after intensive excess volume control. Lowering BP using antihypertensive medications is associated with a reduction in cardiovascular events and mortality in hypertensive patients on hemodialysis,

• Dihydropyridine calcium channel blockers should be considered after β-blockers. No randomized trial has demonstrated that RAAS inhibitors are superior to other antihypertensive agents in the dialysis population.

• More investigations are required to determine the class of antihypertensive agents that is most beneficial in terms of improving the cardiovascular event and mortality rates in patients on dialysis. Further trials are needed in the dialysis population to identify appropriate individualized strategies for determining the target BP and controlling BP by pharmacotherapy.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This manuscript was not funded.