Blood pressure management in hemodialysis: what have we learned?

To review recent developments in the field of hypertension in hemodialysis patients.

Despite the fact that hypertension is the most common complication of end-stage kidney disease, no evidence-based blood pressure (BP) targets exist for hemodialysis patients. There is growing evidence that outcomes are better predicted by out-of-office BP values, such as home or ambulatory BP monitoring. Intradialytic hypertension is associated with increased risk of death or hospitalization, and is probably mediated by volume overload. BP management should focus on volume control: dry weight 'probing' is well tolerated and effective in lowering BP, as are other strategies that minimize expansion of the extracellular fluid volume, such as avoidance of hypernatric dialysate. We discuss each of these issues in our review.

Modest advances in the understanding of hypertension have occurred in the past 2 years. Clinical trials that focus on BP targets and treatment choices are essential to guide future practice.