Interdialytic Hypertension—An Update

  • Rajiv Agarwal
    Address correspondence to Rajiv Agarwal, MD, Division of Nephrology, Department of Medicine, Indiana University and RLR VA Medical Center, 1481 West 10th Street, 111N, Indianapolis, IN 46202.
    Division of Nephrology, Department of Medicine, Indiana University School of Medicine and Roudebush VA Medical Center, Indianapolis, IN
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      The reference standard for diagnosing hypertension among hemodialysis patients is 44-hour interdialytic ambulatory blood pressure (BP) recording. However, a more practical way to diagnose and manage hypertension is to measure home BP over the interdialytic interval. In contrast to pre- and postdialysis BP recordings, measurements of BP performed outside the dialysis unit correlate with the presence of left ventricular hypertrophy and directly and strongly with all-cause mortality. Hypervolemia that is not clinically obvious is the most common treatable cause of hypertension among patients with end-stage renal disease; thus, volume control should be the initial therapy to treat hypertension in most hemodialysis patients. To diagnose hypervolemia, continuous blood volume monitoring is emerging as an effective and simple technique. Reducing dietary and dialysate sodium is an often overlooked strategy to improve BP control. Although definitive randomized trials that show cardiovascular benefits of BP lowering among hypertensive hemodialysis have not been performed, emerging evidence suggests that lowering BP might reduce cardiovascular events. The treatment should be guided by BP obtained outside the dialysis unit because predialysis and postdialysis BP are quite variable and agree poorly with measurements obtained outside the dialysis unit. Although the appropriate level to which BP should be lowered remains elusive, current data suggest that interdialytic ambulatory systolic BP should be lowered to <130 mm Hg and averaged home systolic BP to <140 mm Hg. Antihypertensive drugs will be required by most patients receiving thrice weekly dialysis for 4 hours. Beta blockers, dihydropyridine calcium blockers, and agents that block the renin-angiotensin system appear to be effective in lowering BP in these patients.

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