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Published on: June 6, 2025
Hypertension goals in advanced-stage kidney disease
Keith Hopkins1, George L Bakris
1Department of Medicine, Section of Endocrinology, Diabetes and Metabolism, Hypertensive Diseases Unit, University of Chicago Pritzker School of Medicine, Chicago, Illinois, USA.
Insights
Hypertension in hemodialysis patients poses high cardiovascular risks. Measuring blood pressure (BP) at home or via ambulatory monitoring may offer better risk assessment than traditional dialysis unit readings.
Area of Science:
- Nephrology
- Cardiology
- Hypertension Management
Background:
- Hypertension significantly increases cardiovascular (CV) risks in hemodialysis (HD) patients.
- Current guidelines lack specific recommendations for BP targets and measurement timing in HD populations.
- A U-shaped mortality curve exists, with risks elevated at both low (<120 mmHg) and high (>180 mmHg) pre-dialysis BP levels.
Purpose of the Study:
- To review current strategies for measuring blood pressure (BP) in hemodialysis patients.
- To identify optimal methods for BP assessment to guide cardiovascular risk reduction.
- To highlight the need for clinical trials to validate new BP measurement techniques.
Main Methods:
- Review of existing literature on BP measurement in hemodialysis patients.
- Comparison of peridialysis, home BP, and ambulatory BP monitoring (ABPM) methods.
- Discussion of the relationship between BP levels, mortality, and vascular compliance.
Main Results:
- Peridialysis BP readings are often biased and less representative of true CV risk.
- Home BP and 24-hour ambulatory BP monitoring (ABPM) provide narrower BP ranges potentially linked to reduced CV risk.
- Home BP measurements on interdialytic days correlate well with ABPM and are practical.
Conclusions:
- Accurate BP measurement timing and methods are crucial for managing CV risk in HD patients.
- Home BP and ABPM show promise but require clinical validation through outcome trials.
- Aggressive volume management is essential for effective BP control in this population.
Abstract:
Hypertension confers higher cardiovascular (CV) risks in hemodialysis (HD) patients. There are no data to guide the level to which BP should be reduced or when and where to measure BP in such patients. Unlike BP guidelines to reduce CV risk in the general population, no uniform guidelines address the HD patient. This article focuses on when and how to measure BP and efforts to quantify this measure in the HD-dependent patient. A U-shaped curve exists between BP level and mortality in HD patients, with higher mortality noted at lower levels of BP <120 mmHg and levels >180 mmHg measured before HD. Previous studies examined risk reduction through evaluating BP readings from dialysis units. Peridialysis values were biased and, thus, less representative of risk. Newer studies using home BP and ambulatory BP during 24 h have provided a narrower range of BP values that may reduce CV risk but must be tested in a clinical trial. Ambulatory BP monitoring is a growing tool for hypertension evaluation along with changes in vascular compliance; however, these methods are mainly used in research settings. Home BP values on interdialytic days are practical and also demonstrate good correlations with ambulatory readings. Aggressive volume control seems key to maintaining good BP control. Once a valid time and measure for BP is agreed on, a clinical outcome trial is needed to test its utility.
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