Download Significance of Controlling Hypertension in Patients

Significance of Controlling
Hypertension in Patients with EndStage Renal Disease
Source: Horl WH. Hypertension in endstage renal disease: Different measures
and their prognostic significance.
Nephrol Dial Transplant. 2010:1–6.
• Blood pressure (BP) control might be an important target for the
intervention to reduce cardiovascular mortality in the majority of
hypertensive patients who start dialysis.
• No consensus exists as to lower increased BP in hemodialysis (HD)
patients or the level to which BP
• should be targeted.
• In addition, the accurate assessment of BP is difficult in this patient
population.
• National Kidney Foundation Disease Outcomes Quality Initiative
(NKFKDOQI)- recommended peridialytic BP targets of <140/90
mmHg predialytic and <130/80 mmHg postdialytic results in an
increased frequency of intradialytic hypotension.
• Peridialytic BP measurements are used for the management of
hypertension in the majority of HD patients.
• Predialysis systolic BP between 140 and 160 mmHg and a
predialysis diastolic BP between 70 and 90 mmHg is recommended
in HD patients to reduce the risk of mortality.
• A study found that a predialysis systolic BP <120 mmHg was
associated with a higher risk of mortality compared with the
reference group with a predialysis systolic BP between 140 and 159
mmHg.
• The patterns of systolic BP, diastolic BP, mean arterial pressure
(MAP) and pulse pressure (PP) in HD patients differs markedly with
that of the general population.
• An increase in systolic BP, diastolic BP, MAP and PP was observed
among young HD patients reflecting an acceleration of
cardiovascular diseases in these patients.
• This suggests that in this subgroup of patients, BP-lowering therapy
may be beneficial.
• Dry-Weight Reduction in Hypertensive Hemodialysis (DRIP) trial
supports the use of home BP measurement in HD patients.
• After 18–30 h of completion of the dialysis treatment, home BP
measurements are recommended.
• In the absence of home BP monitoring among HD patients,
intradialytic BP recordings may improve the diagnosis and
management of hypertension.
• Most patients undergoing HD require a number of antihypertensives in
order to achieve the appropriate BP.
• All classes of antihypertensives are used for controlling hypertension in HD
patients; however, only a few HD patients may benefit from loop diuretics.
• The metaanalysis by Agarwal and Sinha showed a cardiovascular benefit
for hypertensive HD patients from BP lowering.
• In a systemic review and meta-analyses of eight trials with data from 1,649
patients and 495 cardiovascular events performed to evaluate the effect
of lowering the BP on cardiovascular events and mortality in patients on
dialysis, it was found that reduction of BP was associated with lower risk
of cardiovascular events, all cause mortality and cardiovascular mortality
than control regimens.
• This is shown in Table 1.
• However, this result cannot be generalized for a large
number of patients worldwide due to the clinical disparity
in trials included for meta-analysis.
• Use of angiotensin II receptor blockers (ARBs) reduces the
number of deaths from congestive heart failure.
• Amlodipine showed a significant reduction in the
composite secondary endpoint of all-cause mortality or a
cardiovascular event. Owing to hypotension,
• hyperkalemia, and adverse metabolic effects with the use
• of 􀁅-blockers, this class of drug is sparingly used in highrisk
• patients. The treatment with angiotensin-converting
• enzyme inhibition or ARB in HD patients shows reduced
• left ventricular mass. For subjects without kidney disease
• and with or without significant cardiovascular disease
• burdens, any form of the BP-reducing therapy profoundly
• reduced cardiovascular burdens.
• A direct relationship between volume status and BP has been
recognized in patients with end-stage renal disease (ESRD) treated
with dialysis.
• An increase in the predialytic systolic BP may reflect hypervolemia.
Data from the CLIMB study, which was obtained from 442 subjects
in 32,295 sessions and followed up for 6 months, confirmed that an
increasing percentage of interdialytic weight gain (IDWG) is
associated with a greater predialysis BP and a greater decrease in
BP associated with HD.
• A 15% or greater extracellular volume increase over the normal in
HD patients increases the risk of mortality.
• In the CLIMB study it was observed that peritoneal dialysis patients
responded positively to a combined therapy of salt restriction (4
g/day, body weight) plus additional ultrafiltration by the addition of
hypertonic dextrose solutions, which led to a significant decrease in
the systolic and the diastolic BP. In dialysis patients, salt and water
overload raises the BP.
• Lifestyle modification is the key to restrict the
dietary sodium intake.
• The study have impressively demonstrated
• that a dietary salt restriction for >36 months
results in a decrease in the following
parameters in maintenance HD patients (see
Table 2).
• A study assessed cardiac consequences of two different
strategies for BP control in maintenance HD patients.
• One group was put on salt a restriction (5 g/day)
whereas the other group was given antihypertensive
drugs.
• Patients in the group who were put on salt restriction
had significantly lower IDWG, lower left ventricular
mass, lower frequency of left ventricular hypertrophy,
better preserved systolic and diastolic functions and
lower episodes of intradialytic hypotension in spite of
similar systolic and diastolic BP values.
• This may be possible as antihypertensive drugs may
interfere with the compensatory vasoconstriction in BP
maintenance in the face of rapid changes in
intravascular volume during conventional HD.
• Parallel reductions in awake and sleep BP without
restoring a nocturnal dipping in HD patients is
observed with augmented volume removal
therapy.
• Volume removal therapy reduces the systolic BP
greater than the diastolic BP, which results in the
reduction of PP, which has an impact on the
survival of HD patients.
• An increased death risk is associated with
postdialysis PP >60 mmHg, but also for predialysis
PP <55 mmHg. Lowering of the PP from before to
after HD was associated with lower
hospitalization and lower mortality outcomes.
• Intradialytic hypertension may be a sign of
volume excess.
• Endothelin excess, sympathetic overactivity,
activation of the renin–angiotensin–aldosterone
system, or dialysisspecific factors, such as net
sodium gain, high dialysate calcium, hypokalemia
or removal of hypertensive medications can raise
the intradialytic BP.
• Though recommendations to treat intradialytic
hypertension exist, these recommendations are
not validated by studies.
• In ESRD patients, long, slow, home HD or
frequent, short HD sessions or nocturnal HD also
result in the reduction of BP and left ventricular
hypertrophy.
• Thrice-weekly incenter nocturnal HD is an
effective strategy to optimize BP, which is
supported with a study.
• The study found a decrease in the systolic and the
diastolic BP in seven maintenance HD patients at
2 years after starting nocturnal HD.
• The results are shown in Table 3.
• Normalization of BP associated with a significant
reduction in the use of per patient antihypertensive
agents.
• The IDWG is associated with cardiovascular mortality.
• Thus, lowering dialysate sodium might prevent IDWG
and possibly decrease mortality.
• To conclude, hypertension should be treated effectively
as it affects a vast majority of HD patients.
• Normovolemia is the key therapeutic target for
hypertension in HD patients that can be achieved by
ultrafiltration and dietary salt restriction.
• Antihypertensive drugs may reduce cardiovascular
complications, but a generalization cannot be made for
heterogeneous patients undergoing HD.
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