Optimal blood pressure level and best measurement procedure in hemodialysis patients

Hypertension occurs frequently among hemodialysis (HD) patients and can be due to many factors, such as salt intake, elevated sympathetic tone, and uremic toxins. It is responsible for the high cardiovascular risk associated with renal disease. Generally, in HD patients, while there is an elevation of systolic blood pressure (BP), diastolic BP seems to decrease, and the resultant effect is high pulse pressure, which can have a deleterious effect on the cardiovascular system. Although controversial, in the HD population the relationship between BP and risk of death seems to be U shaped, probably because of pre-existing cardiac disease in patients with the lowest BP. In chronic kidney disease, BP lower than 130/80 mmHg is recommended, but an appropriate target for BP in the HD population remains to be established. Moreover, there is no consensus regarding which routine peridialysis BP (pre- or post-dialysis BP, or both) can ensure the diagnosis of hypertension in this population. Ambulatory BP monitoring remains the gold standard to quantify the integrated BP load applied to the cardiovascular system. As well, home BP assessment could contribute to improve the definition of an optimal BP in the HD population. An ideal goal for post-dialysis systolic BP seems to be a value higher than 110 mmHg and lower than 150 mmHg. However, HD patients are generally old and often have cardiac complications, so a reasonable pre-dialysis target systolic BP could be 150 mmHg. It is prudent to suggest that an improvement in BP control is necessary in the HD population, first by slow and smooth removal of extracellular volume (dry weight) and thereafter by the use of appropriate antihypertensive medication.