Blood pressure management in patients receiving renal replacement therapy

Hypertension is the most common complication of kidney disease, diabetes, and other cardiovascular diseases. In addition, it is a critical factor in the progression of these diseases, and hence, blood pressure management is highly recommended worldwide, in accordance with the major guidelines. However, there are two blind spots in the management system: one concerns patients with cancer, and the other concerns patients receiving renal replacement therapy. End-stage renal failure is the final stage of hypertension, and nephrologists usually treat hypertension in both nondialysis patients and dialysis patients. Nephrologists first attempt to manage the blood pressure of dialysis patients using the same method employed for nondialysis patients, i.e., by deciding on a target blood pressure at the clinic. However, this is exceedingly difficult because dialysis patients have lost their most important body-fluid autoregulatory mechanism and have varying body weights during the dialysis session. Moreover, numerous lines of evidence and clinicians' observations have suggested that hypotension during a dialysis session leads to an unfavorable prognosis. However, when the target blood pressure is increased to avoid hypotension during a dialysis session, the risk of atherosclerosis and bleeding complications will be increased. Many nephrologists may feel unsure of choosing a target blood pressure using traditional methods. Recently, home blood pressure and average blood pressure have become new indices of blood pressure management. We believe that further advancements of this old and important theme will be possible with new technologies and big-data analytical methods.