The internist's role in treating hypertension in hemodialysis patients

Hypertension in hemodialysis patients is typically treated with a combination of volume removal with dialysis--although limited by current dialysis paradigms--and hypertension medications. Unfortunately, most patients treated in this manner remain hypertensive. This contrasts with superior results obtained in clinical studies in which salt restriction and augmented dialytic volume removal normalized blood pressure without requiring medicines. These results are consistent with the role of excess volume as the main etiology of hypertension in end-stage renal disease (ESRD). Interdialytic blood pressure is now recognized as important to patient prognosis. These measurements are frequently obtained by internists at office visits. Internists and nephrologists should address both peri-dialysis and interdialysis hypertension in a collaborative manner. This strategy should focus on, as much as reasonably possible, salt restriction and dialytic volume removal rather than hypertension medicines.