Blood pressure in haemodialysis: measurement, volume control and drug selection

Hypertension in haemodialysis is common, prognostically important, and difficult to manage because blood pressure measurement is often imprecise, extracellular volume is dynamic, and low blood pressure may reflect heart failure, frailty, impaired forward flow, autonomic dysfunction, or excessive ultrafiltration rather than therapeutic success. Contemporary evidence supports ambulatory blood pressure monitoring as the reference standard and home blood pressure monitoring as the most practical longitudinal method, while accepted targets remain unsettled. Treatment should begin with standardised assessment of interdialytic blood pressure burden and sodium-volume control through dietary sodium restriction, dialysate sodium consideration, dry-weight reassessment, ultrafiltration management, and adequate treatment time. This sequence helps distinguish true treatment resistance from pseudoresistance caused by dialysis-unit measurement artefacts, volume excess, short treatment time, sodium burden, medication nonadherence, poorly timed dosing, or dialytic drug removal. Once persistent hypertension is confirmed despite sodium-volume and dry-weight-oriented care, pharmacotherapy becomes necessary. Beta-blockers have the strongest outcome-linked support in haemodialysis, whereas calcium channel blockers (CCBs) are practical complementary agents, and conventional renin-angiotensin system (RAS) blockade is best reserved for selected indications. Mineralocorticoid receptor antagonists (MRAs) should be considered cautiously because recent large dialysis trials and updated meta-analytic evidence have not confirmed clear cardiovascular benefit. Sacubitril/valsartan is biologically plausible when hypertension coexists with heart failure with reduced ejection fraction, left ventricular dysfunction, recurrent congestion, or high natriuretic peptide burden. However, it should be framed as a promising but not yet established selective option rather than routine escalation therapy.