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AdvancingDialysis.org
Hypertension in
Dialysis Patients
A consensus document by the EURECA-m working
group of the ERA-EDTA and the Hypertension and the
Kidney working group of the ESH
Journal of Hypertension. 2017 Apr; 35(4):657-676.
AdvancingDialysis.org
Important information
All forms of hemodialysis, including treatments performed in-center and at home, involve
some risks. When vascular access is exposed to more frequent use, infection of the site,
and other access related complications may also be potential risks. In addition, there are
certain risks unique to treatment in the home environment. Patients differ and not everyone
will experience the reported benefits of more frequent hemodialysis.
Certain risks associated with hemodialysis treatment are increased when performing solo
home hemodialysis because no one is present to help the patient respond to health
emergencies.
Certain risks associated with hemodialysis treatment are increased when performing
nocturnal therapy due to the length of treatment time and because therapy is performed
while the patient and care partner are sleeping.
AdvancingDialysis.org
Hypertension is common in
dialysis patients1
Elevated blood pressure,
measured by ambulatory blood
pressure monitoring, is clearly
associated with shorter
survival2-5
Appropriate treatment requires
understanding of the principal
causes of hypertension6
1DOPPS http://www.dopps.org/DPM
2Alborzi, P., Patel, N., and Agarwal, R. Home blood pressures are of greater prognostic value than hemodialysis unit
recordings. Clin J Am Soc Nephrol. 2007; 2: 1228–1234.
3Agarwal, R. Blood pressure and mortality among hemodialysis patients. Hypertension. 2010; 55: 762–768.
4Agarwal, R. The controversies of diagnosing and treating hypertension among hemodialysis patients. Semin Dial. 2012; 25:
370–376.
5Agarwal, R. Pro: Ambulatory blood pressure should be used in all patients on hemodialysis. Nephrol Dial Transplant. 2015;
30: 1432–1437.
6Sarafidis PA, et al. Hypertension in dialysis patients. J Hypertens. 2017;35(4):657-676
Background
AdvancingDialysis.org
• Volume overload
• Arterial stiffness increase
• Sympathetic nervous system
activation
• Renin-angiotensin-aldosterone
system activation
• Endothelial dysfunction
• Sleep apnea
• Erythropoietin-stimulating agents
Numerous Causes of Hypertension1
1Sarafidis PA, et al. Hypertension in dialysis patients. J Hypertens. 2017;35(4):657-676
2DOPPS http://www.dopps.org/DPM
AdvancingDialysis.org
Progressive Pathophysiology
Uncontrolled hypertension1
Left ventricular hypertrophy
Heart failure
Cardiac arrhythmias
Sudden cardiac death
1Zipes DP, Libby P, Bonow RO, Mann DL, Tomaselli GF. Braunwald’s Heart Disease: A Textbook of Cardiovascular
Medicine. 11th ed. Elsevier; 2018.
AdvancingDialysis.org
0
1
2
3
4
5
6
7
2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
Deathsper100patient-years
Sudden cardiac death
Acute myocardial infarction
One-year
cardiovascular mortality
rates in adult dialysis
patients, by primary
cause of death,
according to the Death
Notification form1
1Wetmore JB, Gilbertson DT, Liu J, Collins AJ. Improving outcomes in patients receiving dialysis: The Peer Kidney Care Initiative,
Clin J Am Soc Nephrol. 2016 Jul 7;11(7):1297-304. Figure 4.5.
No Recent Progress in
Sudden Cardiac Death
AdvancingDialysis.org
Bottom Line
+ Key Causes
of Hypertension1
“Sodium and volume excess appear to be the most
important causes of hypertension in dialysis patients” 1
1Sarafidis PA, et al. Hypertension in dialysis patients. J Hypertens. 2017;35(4):657-676
AdvancingDialysis.org
Volume Overload
• Even when residual renal function is preserved, sodium and fluid excretory
capacity is substantially impaired
• Sodium retention and volume overload is often not easily identifiable
• ESRD patients have the highest sodium-sensitivity of blood pressure
• Sodium retention may occur in the form of osmotically inactive sodium in
the connective tissue and skin
Sarafidis PA, et al. Hypertension in dialysis patients. J Hypertens. 2017;35(4):657-676.
AdvancingDialysis.org
“Until fluid and sodium
overload is removed
during dialysis, a rise in
peripheral vascular
resistance will sustain
hypertension in these
individuals.”1
1Sarafidis PA, et al. Hypertension in dialysis patients. J Hypertens. 2017;35(4):657-676
2Zoccali C et al. Chronic fluid overload and mortality in ESRD. J Am Soc Nephrol. 2017 Aug;28(8):2491-2497.
AdvancingDialysis.org
Challenges with Thrice-weekly
Hemodialysis
1Rocco MV, Burkart JM. Prevalence of missed treatments and early sign-offs in hemodialysis patients. J Am Soc
Nephrol. 1993 Nov;4(5):1178-83.
Fluid
Overload1
Uncontrolled
Hypertension
Left Ventricular
Hypertrophy
Heart Failure
Hospitalizations
and Death
“Early Sign-offs”
and “No-Shows”
High
Ultrafiltration
Rate
Intradialytic
Hypotension
Cramping,
Dizziness,
Nausea, etc.
Long Post-Dialysis
Recovery Time
Poor QOL
Cardiac &
organ system
Stunning
AdvancingDialysis.org
Treatment Strategies1
Non-pharmacological strategies Pharmacological strategies
Management of hypertension in dialysis patients should focus at
correction of the primary pathogenetic mechanisms, that is
sodium and volume excess.
1Sarafidis PA, et al. Hypertension in dialysis patients. J Hypertens. 2017;35(4):657-676.
AdvancingDialysis.org
Non-pharmacological Strategies to
Reduce Blood Pressure
Reduce salt intake
Individualize dialysate sodium
Increase treatment length
and frequency
Reduce salt intake1
• Reducing the amount of sodium gained
from diet or dialysate fluid is critical to
achieve BP control
• Dietary sodium restriction appears to be
an effective approach to limit sense of
thirst, reduce interdialytic weight gain and
facilitate achievement of dry-weight and
BP control
1Sarafidis PA, et al. Hypertension in dialysis patients. J Hypertens. 2017;35(4):657-676.
AdvancingDialysis.org
Non-pharmacological Strategies to
Reduce Blood Pressure
Reduce salt intake
Individualize dialysate sodium
Increase treatment length
and frequency
Individualize dialysate sodium1
• Recent research has emphasized that a
high-dialysate sodium concentration may
increase thirst and interdialytic weight gain
• A consensus document by the Chief
Medical Officers of US Dialysis Providers
warns against the use of dialysate with a
sodium concentration exceeding
predialysis serum sodium
1Sarafidis PA, et al. Hypertension in dialysis patients. J Hypertens. 2017;35(4):657-676.
AdvancingDialysis.org
Non-pharmacological Strategies to
Reduce Blood Pressure
Reduce salt intake
Individualize dialysate sodium
Increase treatment length
and frequency
Increase treatment length
and frequency1
• Length of dialysis session must not be
decided only on the grounds of optimal Kt/V
• Hemodialysis patients should receive at least 3
dialysis sessions of 4 hours each per week
• Increasing duration of dialysis may represent
an additional approach to control BP
• Patients assigned to longer or more frequent
dialysis regimens achieve better BP control
with reduced requirements for antihypertensive
medications
1Sarafidis PA, et al. Hypertension in dialysis patients. J Hypertens. 2017;35(4):657-676.
AdvancingDialysis.org
1Kotanko P, Garg AX, Depner T., et al.; FHN Trial Group. Effects of frequent hemodialysis on blood pressure: Results
from the randomized frequent hemodialysis network trials. Hemodial Int. 2015;19(3):386-401.
2Culleton BF, Walsh M, Klarenbach SW, et al. Effect of frequent nocturnal hemodialysis vs conventional hemodialysis
on left ventricular mass and quality of life: a randomized controlled trial. JAMA. 2007;298(11):1291-9.
More Frequent Hemodialysis
Reduces Blood Pressure
1
1
2
AdvancingDialysis.org
More Frequent Hemodialysis
Reduced Need for Prescribed
Antihypertensive Medication
1Kotanko P, Garg AX, Depner T., et al.; FHN Trial Group. Effects of frequent hemodialysis on blood pressure:
Results from the randomized frequent hemodialysis network trials. Hemodial Int. 2015;19(3):386-401.
2Jaber BL, Collins AJ, Finkelstein FO, et al. Daily hemodialysis reduces the need for anti-hypertensive
medications. Abstract. Renal Week 2009, San Diego, CA.
AdvancingDialysis.org
1Sarafidis PA, et al. Hypertension in dialysis patients. J Hypertens. 2017;35(4):657-676.
Pharmacological Strategies1
Beta blockers Calcium channel blockers
ACE inhibitors
& ARBs
Mineralocorticoid receptor
antagonists
Administration of antihypertensive drug therapy in dialysis
patients considered to be volume overloaded should follow the
attainment of dry-weight.
AdvancingDialysis.org
Key Takeaways
FINDING1
• Salt and water are foremost
problems
• Nonpharmacologic
interventions targeting sodium
and volume excess are
fundamental—and should be
carefully implemented before
pharmacological interventions
RECOMMENDATION1
• Limit sodium exposure from diet
or dialysate
• Increase treatment length and
frequency
1Sarafidis PA, et al. Hypertension in dialysis patients. J Hypertens. 2017;35(4):657-676.
AdvancingDialysis.org
Broader context as summarized by Dr. Allan J. Collins:
Chief Medical Officer for NxStage Medical, Inc.
University of Minnesota School of Medicine
• Persistent hypertension is found in more than half of the dialysis population, making it a
fundamental and unmet challenge in dialysis
• The link between hypertension, left ventricular hypertrophy, heart failure, and sudden death is
clinically clear—effective interventions, however, have been lacking
• Dietary control of salt intake is challenging to address, but also critical
• More frequent HD has consistently been associated with significant improvement in BP
control and regression of LVH
• Additional research is needed to assess the impact of more frequent HD on sudden death
Dr. Collins has held several leadership roles at the National Kidney Foundation (NKF), serving as president for two
years, and on the NKF scientific advisory board for six years, and with the Kidney Dialysis Outcomes Quality Initiative.
Dr. Collins is the Chief Medical Officer for NxStage Medical, Inc.
AdvancingDialysis.org
About this presentation
This presentation is one in an ongoing series focused on recent articles, clinical findings or
guidelines related to issues affecting dialysis patients.
AdvancingDialysis.org is dedicated to providing clinicians and patients with better access to and
more awareness of the reported clinical benefits and improved quality of life made possible with
home dialysis, including more frequent, solo, more intensive, and nocturnal therapy schedules.
For more information, visit AdvancingDialysis.org
AdvancingDialysis.org is a project of NxStage Medical, Inc.
AdvancingDialysis.org
www.AdvancingDialysis.org
© 2018 NxStage Medical, Inc.

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Advancing Dialysis Hypertension in Dialysis Patients

  • 1. AdvancingDialysis.org Hypertension in Dialysis Patients A consensus document by the EURECA-m working group of the ERA-EDTA and the Hypertension and the Kidney working group of the ESH Journal of Hypertension. 2017 Apr; 35(4):657-676.
  • 2. AdvancingDialysis.org Important information All forms of hemodialysis, including treatments performed in-center and at home, involve some risks. When vascular access is exposed to more frequent use, infection of the site, and other access related complications may also be potential risks. In addition, there are certain risks unique to treatment in the home environment. Patients differ and not everyone will experience the reported benefits of more frequent hemodialysis. Certain risks associated with hemodialysis treatment are increased when performing solo home hemodialysis because no one is present to help the patient respond to health emergencies. Certain risks associated with hemodialysis treatment are increased when performing nocturnal therapy due to the length of treatment time and because therapy is performed while the patient and care partner are sleeping.
  • 3. AdvancingDialysis.org Hypertension is common in dialysis patients1 Elevated blood pressure, measured by ambulatory blood pressure monitoring, is clearly associated with shorter survival2-5 Appropriate treatment requires understanding of the principal causes of hypertension6 1DOPPS http://www.dopps.org/DPM 2Alborzi, P., Patel, N., and Agarwal, R. Home blood pressures are of greater prognostic value than hemodialysis unit recordings. Clin J Am Soc Nephrol. 2007; 2: 1228–1234. 3Agarwal, R. Blood pressure and mortality among hemodialysis patients. Hypertension. 2010; 55: 762–768. 4Agarwal, R. The controversies of diagnosing and treating hypertension among hemodialysis patients. Semin Dial. 2012; 25: 370–376. 5Agarwal, R. Pro: Ambulatory blood pressure should be used in all patients on hemodialysis. Nephrol Dial Transplant. 2015; 30: 1432–1437. 6Sarafidis PA, et al. Hypertension in dialysis patients. J Hypertens. 2017;35(4):657-676 Background
  • 4. AdvancingDialysis.org • Volume overload • Arterial stiffness increase • Sympathetic nervous system activation • Renin-angiotensin-aldosterone system activation • Endothelial dysfunction • Sleep apnea • Erythropoietin-stimulating agents Numerous Causes of Hypertension1 1Sarafidis PA, et al. Hypertension in dialysis patients. J Hypertens. 2017;35(4):657-676 2DOPPS http://www.dopps.org/DPM
  • 5. AdvancingDialysis.org Progressive Pathophysiology Uncontrolled hypertension1 Left ventricular hypertrophy Heart failure Cardiac arrhythmias Sudden cardiac death 1Zipes DP, Libby P, Bonow RO, Mann DL, Tomaselli GF. Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine. 11th ed. Elsevier; 2018.
  • 6. AdvancingDialysis.org 0 1 2 3 4 5 6 7 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 Deathsper100patient-years Sudden cardiac death Acute myocardial infarction One-year cardiovascular mortality rates in adult dialysis patients, by primary cause of death, according to the Death Notification form1 1Wetmore JB, Gilbertson DT, Liu J, Collins AJ. Improving outcomes in patients receiving dialysis: The Peer Kidney Care Initiative, Clin J Am Soc Nephrol. 2016 Jul 7;11(7):1297-304. Figure 4.5. No Recent Progress in Sudden Cardiac Death
  • 7. AdvancingDialysis.org Bottom Line + Key Causes of Hypertension1 “Sodium and volume excess appear to be the most important causes of hypertension in dialysis patients” 1 1Sarafidis PA, et al. Hypertension in dialysis patients. J Hypertens. 2017;35(4):657-676
  • 8. AdvancingDialysis.org Volume Overload • Even when residual renal function is preserved, sodium and fluid excretory capacity is substantially impaired • Sodium retention and volume overload is often not easily identifiable • ESRD patients have the highest sodium-sensitivity of blood pressure • Sodium retention may occur in the form of osmotically inactive sodium in the connective tissue and skin Sarafidis PA, et al. Hypertension in dialysis patients. J Hypertens. 2017;35(4):657-676.
  • 9. AdvancingDialysis.org “Until fluid and sodium overload is removed during dialysis, a rise in peripheral vascular resistance will sustain hypertension in these individuals.”1 1Sarafidis PA, et al. Hypertension in dialysis patients. J Hypertens. 2017;35(4):657-676 2Zoccali C et al. Chronic fluid overload and mortality in ESRD. J Am Soc Nephrol. 2017 Aug;28(8):2491-2497.
  • 10. AdvancingDialysis.org Challenges with Thrice-weekly Hemodialysis 1Rocco MV, Burkart JM. Prevalence of missed treatments and early sign-offs in hemodialysis patients. J Am Soc Nephrol. 1993 Nov;4(5):1178-83. Fluid Overload1 Uncontrolled Hypertension Left Ventricular Hypertrophy Heart Failure Hospitalizations and Death “Early Sign-offs” and “No-Shows” High Ultrafiltration Rate Intradialytic Hypotension Cramping, Dizziness, Nausea, etc. Long Post-Dialysis Recovery Time Poor QOL Cardiac & organ system Stunning
  • 11. AdvancingDialysis.org Treatment Strategies1 Non-pharmacological strategies Pharmacological strategies Management of hypertension in dialysis patients should focus at correction of the primary pathogenetic mechanisms, that is sodium and volume excess. 1Sarafidis PA, et al. Hypertension in dialysis patients. J Hypertens. 2017;35(4):657-676.
  • 12. AdvancingDialysis.org Non-pharmacological Strategies to Reduce Blood Pressure Reduce salt intake Individualize dialysate sodium Increase treatment length and frequency Reduce salt intake1 • Reducing the amount of sodium gained from diet or dialysate fluid is critical to achieve BP control • Dietary sodium restriction appears to be an effective approach to limit sense of thirst, reduce interdialytic weight gain and facilitate achievement of dry-weight and BP control 1Sarafidis PA, et al. Hypertension in dialysis patients. J Hypertens. 2017;35(4):657-676.
  • 13. AdvancingDialysis.org Non-pharmacological Strategies to Reduce Blood Pressure Reduce salt intake Individualize dialysate sodium Increase treatment length and frequency Individualize dialysate sodium1 • Recent research has emphasized that a high-dialysate sodium concentration may increase thirst and interdialytic weight gain • A consensus document by the Chief Medical Officers of US Dialysis Providers warns against the use of dialysate with a sodium concentration exceeding predialysis serum sodium 1Sarafidis PA, et al. Hypertension in dialysis patients. J Hypertens. 2017;35(4):657-676.
  • 14. AdvancingDialysis.org Non-pharmacological Strategies to Reduce Blood Pressure Reduce salt intake Individualize dialysate sodium Increase treatment length and frequency Increase treatment length and frequency1 • Length of dialysis session must not be decided only on the grounds of optimal Kt/V • Hemodialysis patients should receive at least 3 dialysis sessions of 4 hours each per week • Increasing duration of dialysis may represent an additional approach to control BP • Patients assigned to longer or more frequent dialysis regimens achieve better BP control with reduced requirements for antihypertensive medications 1Sarafidis PA, et al. Hypertension in dialysis patients. J Hypertens. 2017;35(4):657-676.
  • 15. AdvancingDialysis.org 1Kotanko P, Garg AX, Depner T., et al.; FHN Trial Group. Effects of frequent hemodialysis on blood pressure: Results from the randomized frequent hemodialysis network trials. Hemodial Int. 2015;19(3):386-401. 2Culleton BF, Walsh M, Klarenbach SW, et al. Effect of frequent nocturnal hemodialysis vs conventional hemodialysis on left ventricular mass and quality of life: a randomized controlled trial. JAMA. 2007;298(11):1291-9. More Frequent Hemodialysis Reduces Blood Pressure 1 1 2
  • 16. AdvancingDialysis.org More Frequent Hemodialysis Reduced Need for Prescribed Antihypertensive Medication 1Kotanko P, Garg AX, Depner T., et al.; FHN Trial Group. Effects of frequent hemodialysis on blood pressure: Results from the randomized frequent hemodialysis network trials. Hemodial Int. 2015;19(3):386-401. 2Jaber BL, Collins AJ, Finkelstein FO, et al. Daily hemodialysis reduces the need for anti-hypertensive medications. Abstract. Renal Week 2009, San Diego, CA.
  • 17. AdvancingDialysis.org 1Sarafidis PA, et al. Hypertension in dialysis patients. J Hypertens. 2017;35(4):657-676. Pharmacological Strategies1 Beta blockers Calcium channel blockers ACE inhibitors & ARBs Mineralocorticoid receptor antagonists Administration of antihypertensive drug therapy in dialysis patients considered to be volume overloaded should follow the attainment of dry-weight.
  • 18. AdvancingDialysis.org Key Takeaways FINDING1 • Salt and water are foremost problems • Nonpharmacologic interventions targeting sodium and volume excess are fundamental—and should be carefully implemented before pharmacological interventions RECOMMENDATION1 • Limit sodium exposure from diet or dialysate • Increase treatment length and frequency 1Sarafidis PA, et al. Hypertension in dialysis patients. J Hypertens. 2017;35(4):657-676.
  • 19. AdvancingDialysis.org Broader context as summarized by Dr. Allan J. Collins: Chief Medical Officer for NxStage Medical, Inc. University of Minnesota School of Medicine • Persistent hypertension is found in more than half of the dialysis population, making it a fundamental and unmet challenge in dialysis • The link between hypertension, left ventricular hypertrophy, heart failure, and sudden death is clinically clear—effective interventions, however, have been lacking • Dietary control of salt intake is challenging to address, but also critical • More frequent HD has consistently been associated with significant improvement in BP control and regression of LVH • Additional research is needed to assess the impact of more frequent HD on sudden death Dr. Collins has held several leadership roles at the National Kidney Foundation (NKF), serving as president for two years, and on the NKF scientific advisory board for six years, and with the Kidney Dialysis Outcomes Quality Initiative. Dr. Collins is the Chief Medical Officer for NxStage Medical, Inc.
  • 20. AdvancingDialysis.org About this presentation This presentation is one in an ongoing series focused on recent articles, clinical findings or guidelines related to issues affecting dialysis patients. AdvancingDialysis.org is dedicated to providing clinicians and patients with better access to and more awareness of the reported clinical benefits and improved quality of life made possible with home dialysis, including more frequent, solo, more intensive, and nocturnal therapy schedules. For more information, visit AdvancingDialysis.org AdvancingDialysis.org is a project of NxStage Medical, Inc.

Editor's Notes

  1. New
  2. Previously Approved (APM2540) There are risks associated with all forms of dialysis, but one item to point out is that certain risks are unique to home as treatments are done without the presence of a medial professional.
  3. New with Previously Approved content (APM2920)
  4. Previously Reviewed (no comments, not approved in Agile)
  5. Changed color – APM2302