Management of Hypertension in Patients Undergoing Peritoneal Dialysis: A Narrative Review

Hypertension is the most common complication in patients with end-stage renal disease (ESRD) on dialysis and a major contributor to cardiovascular mortality. This narrative review explores the multifactorial pathophysiology of hypertension in peritoneal dialysis (PD) patients, including extracellular fluid overload, sodium and water imbalance, sympathetic overactivity, activation of the renin-angiotensin-aldosterone system (RAAS), loss of residual kidney function (RKF), and inflammation with endothelial dysfunction. Current clinical perspectives on blood pressure (BP) management are reviewed, highlighting variations in BP targets, the U-shaped relationship between BP and mortality, and the need for individualized, volume-focused treatment goals. Diagnostic and monitoring strategies such as ambulatory BP monitoring (ABPM), home BP monitoring, standardized office measurements, bioimpedance spectroscopy, and lung ultrasound are discussed for assessing hypertension and volume status. Management approaches include non-pharmacologic strategies, optimization of dry weight, dietary sodium restriction, dwell time adjustments, low-sodium dialysate, icodextrin use for improved ultrafiltration, and physical activity and pharmacologic therapies including ACE inhibitors, angiotensin receptor blockers (ARBs), calcium channel blockers, beta-blockers, diuretics, mineralocorticoid receptor antagonists (MRAs), and agents for resistant hypertension such as clonidine and moxonidine. Special considerations, such as peritonitis, which can alter peritoneal membrane function and ultrafiltration, are also addressed. Emerging therapies, including sodium-glucose co-transporter 2 (SGLT2) inhibitors, novel PD solutions with reduced glucose content, digital BP monitoring platforms, and lung ultrasound for real-time fluid assessment, highlight evolving strategies in this field. In conclusion, hypertension management in PD requires a personalized, volume-targeted, and multidisciplinary approach integrating optimized monitoring, pharmacologic and non-pharmacologic interventions, and supportive lifestyle measures to improve patient outcomes.