[Resistant hypertension and paradox effect in patient with hemodialysis treatment]

This is a case study of a 65-year-old female, on regular haemodialysis treatment, with resistant hypertension and paradoxical blood pressure (BP) elevation during dialysis. This phenomenon occurs in a small number of patients, since in most patients an acceptable BP is usually reached by adequate control of fluid and volume status with dialysis, sometimes associated with pharmacologic intervention. Since in our patient hypertension persisted despite apparent achievement of dry weight and maintenance of antihypertensive medications, we did some extensive investigations to disclose any secondary causes of hypertension (other than ESRD); we also evaluated whether the optimal dry weight was really achieved and maintained, and if the pharmacokinetics of the antihypertensive drugs was influenced by dialysis. We found no secondary cause of hypertension; by contrast, we detected the presence of a mild cardiac dilatation, and realized that some antihypertensive drugs, taken by our patient, were removed by dialysis. Since both these are known to precipitate the paradoxical BP rise during dialysis, we successfully modified once again our dialysis strategy and changed the antihypertensive therapy, adding a calcium antagonist to both losartan and low-dose minoxidil.