HTN Among ESRD Patients Cardiology meeting .pptx

Blood pressure among
Hemodialysis Patients
JAFAR ALSAID, M.B.CHB. MD. FASN. FACP
Assistant Professor University of Queensland.
Nephrology and Interventional Consultant.
Ochsner Medical Center.
1
JAFAR ALSAID.MBCHB. MD. FASN.FACP. Sept 2023

Scheme
• Epidemiology.
• Measurement of BP.
• Intradialytic and Interdialytic BP.
• Central and Peripheral BP.
• Management of BP in Hemodialysis patients.
2

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50
100
150
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250 1
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Pattern of BP variation during multiple HD sessions
For one patient in our unit
HD session Reading # systolic Diastolic

198
169
155 161
142
158 163
150
140
151 147 155
145
131 130 122 113
134
146
157
75 73 70 69 65 71 73 68 68 77 72 65 70 63
45
56 53 59 58
28
0
50
100
150
200
250
0 2 4 6 8 10 12 14 16 18 20
1st HD session
188 192
177
164 174 164 161 171 161 170 169
146 151 144 142 134 123 127
152
94
110
138
167
143
80 81 78 86 86 84 73 73 76
64 69 59 65 70 72 64 63 62
48 53 53 59 65 67
0
50
100
150
200
250
0 5 10 15 20 25
2nd HD session
180 179 181 182
165 168
178 185
159 159 154
173 165 172
163 163 155
137
163
179
77
60
76 77 72 71
93
79 80
67
77 73 74 79
65 72 75 72 68
49
0
20
40
60
80
100
120
140
160
180
200
0 2 4 6 8 10 12 14 16 18 20
3rd HD session
180
155 150
163
137
165
131
148 141 146
172 168 165 172 176
64
87
72 73 74
64
83
73 78
90
67
106
91
80
92
0
20
40
60
80
100
120
140
160
180
200
0.00 2.00 4.00 6.00 8.00 10.00 12.00 14.00 16.00
1st HD session
115
153 156 161
182
193
182 178 169
187
144 142 146 144
172
55 53 60 55 60 68
50
66 67 67 65 61 63 60
77
0
50
100
150
200
250
0.00 2.00 4.00 6.00 8.00 10.00 12.00 14.00 16.00
3rd HD session
143 145 147 146 134 146 136 144 137
122
134 139
126 133 136
68 62 67
55 62 65 59 62 60 51 57 61 58 58 66
0
50
100
150
200
0.00 2.00 4.00 6.00 8.00 10.00 12.00 14.00 16.00
2nd HD session
1st patient 2nd patient
4

5
BP variation during HD in ESRD patients

2017 Annual Data Report
Volume 2, Chapter 1
6

2017 Annual Data Report
Volume 2, Chapter 1
7
Causes of ESRD USRDS 2016

Myocardial
Stunning during
Hemodialysis

Cerebral
Hypoperfusion
during
Hemodialysis

Adjusted 5 years survival for HD Patients
10

Causes of mortality in patient with HD died in 2020
12

Pathophysiology of HTN in Patient treated with Maintenance HD.
JAFAR ALSAID.MBCHB. MD. FASN.FACP. Sept 2023 17
Bansal N., Atinian N., Bakris. J. et.a;.Hypertension in Patients Treated With Hemodialysis. Hypertension. 2023;80:e112–e122

ESH 2023 and American Heart
Association 2023 HTN Guideline
Excluded ESRD Subpopulation
19

https://cdphealth.com/commun
ity-education/blood-pressure-
monitoring-program/

BP measurement During Dialysis
23

BP variation among dialysis patients
• Seasonal variation , higher BP in winter and lower in summer.
• Interpersonal variation.
• Pre and post dialysis BP variation.
• Intradialysis BP variation.
25
Santos SF, Mendes RB, Santos CA, Dorigo D, Peixoto AJ: Profile of interdialytic blood pressure in hemodialysis patients. Am J Nephrol 23: 96–105, 2003.
Mendes RB, Santos SF, Dorigo D, Mansoor GA, Crowley ST,WhiteWB, Peixoto AJ: The use of peridialysis blood pressure and intradialytic blood pressure
changes in the prediction of interdialytic blood pressure in haemodialysis patients. Blood Press Monit 8: 243–248, 2003
Rohrscheib MR, Myers OB, Servilla KS, Adams CD, Miskulin D, Bedrick EJ, Hunt WC, Lindsey DE, Gabaldon D, Zager PG; DCI Medical Directors: Age-related
blood pressure patterns and blood pressure variability among hemodialysis patients. Clin J Am Soc Nephrol 3: 1407–1414, 2008

Intradialytic BP Variability
• Low reproducibility of Pre and Post Dialysis BP.
• High Day to day Variability.
• High Pre to Post Dialysis Variability.
26
Panagiotis I. Georgianos and Rajiv Agarwal. Pressure and Mortality in Long-Term Hemodialysis—
Time to Move Forward. American Journal of Hypertension 30(3) March 2017. 211-222

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276
Which BP to Follow During Dialysis sessions?
•Pre Dialysis.
•Post Dialysis.
•Average Intradialysis.
•Average Intradialysis with Pre and Post dialysis.
•Average Pre and Post Dialysis.
27
Aarawal R. et/al. Diagnosing Hypertension by Intradialytic BP recordings. Clin J Am Soc Nephrol. 2008 Sep; 3(5): 1364-72

CVD outcome:
• Heart failure.
• MI.
Ischemic stroke.
Peripheral Arterial disease.
Death. Death certificates review.
HD subset of the CRIC cohort
31
Bansal N., McCulloch C. et. Al. Blood Pressure and risk of cardiovascular events in patients on chronic HD:
the CRIC Study. Hypertension. 2017 August ; 70(2): 435–443. doi:10.1161/HYPERTENSIONAHA. 117.09091.

Results of the CRIC Hemodialysis subset
• 113 CV events
• Mean time to occur 2.4 years (SD 1.71)
• 59 Heart failure.
• 19 MI.
• 8 Stroke.
• 18 Peripheral Art. Disease.
• 7 with MI & HF.
• 1 MI & AFib.
• 1 MI, stroke & Peripheral Arterial disease.
Hypertension. 2017 August ; 70(2): 435–443. doi:10.1161/HYPERTENSIONAHA.117.09091.
32

Correlation between
Dialysis and Out of
Dialysis systolic BP.
(N=377)
Hypertension. 2017
August ; 70(2): 435–443.
doi:10.1161/HYPERTENSI
ONAHA.117.09091.
33

Hypertension. 2017 August
; 70(2): 435–443.
doi:10.1161/HYPERTENSION
AHA.117.09091.
34
Correlation between
Dialysis and Out of
Dialysis Diastolic BP.
(N=377)

Hypertension. 2017 August ;
70(2): 435–443.
doi:10.1161/HYPERTENSIONAHA.
117.09091.
35
Correlation between
Dialysis and Out of
Dialysis Pulse
Pressure. (N=377)

Multivariable association
of dialysis-unit-systolic
blood pressure with
cardiovascular events
(N=377)
70(2): 435–443.
doi:10.1161/HYPERTENSIONA
HA.117.09091.
150-170
36

Multivariable association
of out-of-dialysis-unit-
systolic blood pressure
with cardiovascular
events (N=377)
70(2): 435–443.
doi:10.1161/HYPERTENSIONAHA.1
17.09091.
37

38

Association between Dialysis unit and out of dialysis BP with CVD
40

Hazard ratios (HRs) for all-cause mortality for increasing
quartiles of systolic out of dialysis BP measurements.
41
Home systolic BP of
125–145 mm Hg &
115–125 mmHg by
ambulatory BP was
associated with the
best prognosis in HD
patients
Alborzi et al. Home blood pressures are of greater prognostic value than hemodialysis unit recordings. Clin J Am Soc Nephrol 2007;
2:1228–34.)
Target BP
<125
126-143
144-157
>158

Malliara M. The management of hypertension in hemodialysis and CAPD patients,HIPPOKRATIA 2007, 11, 4: 171-174
42

Cardiovascular mortality and BP has U curve shape in hemodialysis patients
Zager et al: U Curve association of BP and mortality in HD patients. Kidney International, Vol. 54 (1998), pp. 561–569
43
Post Dialysis Systolic BP
P<0.01
P<0.05
P<0.01

Bias, precision, and accuracy of dialysis unit BP measurements
Agarawal R., et al. Diagnosing Hypertension by Intradialytic Blood Pressure Recordings. Clin J Am Soc
Nephrol. 2008 Sep; 3(5): 1364-137. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2518788/?report=prin
44

45
Agarwal R. Blood pressure and mortality among hemodialysis patients. Hypertension 2010; 55:762–768.
Alborzi P, Patel N, Agarwal R. Home blood pressures are of greater prognostic value than hemodialysis unit recordings. Clin
J Am Soc Nephrol 2007; 2:1228–1234.
Amar J, Vernier I, Rossignol E, Bongard V, Arnaud C, Conte JJ, Salvador M, Chamontin B. Nocturnal blood pressure and
24-hour pulse pressure are potent indicators of mortality in hemodialysis patients. Kidney Int
2000; 57:2485–2491.
Bansal N, McCulloch CE, Rahman M, Kusek JW, Anderson AH, Xie D, Townsend RR, Lora CM, Wright J, Go AS, Ojo A,
Alper A, Lustigova E, Cuevas M, Kallem R, Hsu CY; CRIC Study Investigators. Blood pressure and risk of all-cause
mortality in advanced chronic kidney disease and hemodialysis: the chronic renal insufficiency cohort study. Hypertension
2015; 65:93–100.
Tripepi G, Fagugli RM, Dattolo P, Parlongo G, Mallamaci F, Buoncristiani U, Zoccali C. Prognostic value of 24-hour
ambulatory blood pressure monitoring and of night/day ratio in nondiabetic, cardiovascular events-free hemodialysis
patients. Kidney Int 2005; 68:1294–1302.
Ekart R, Kanič V, Pečovnik Balon B, Bevc S, Hojs R. Prognostic value of 48-hour ambulatory blood pressure measurement
and cardiovascular mortality in hemodialysis patients. Kidney Blood Press Res 2012; 35:326–331.
Moriya H, Oka M, Maesato K, Mano T, Ikee R, Ohtake T, Kobayashi S. Weekly averaged blood pressure is more important
than a singlepoint blood pressure measurement in the risk stratification of dialysis patients. Clin J Am Soc Nephrol 2008;
3:416–422.
Agarwal R, Andersen MJ, Light RP. Location not quantity of blood pressure measurements predicts mortality in
hemodialysis patients. Am J Nephrol 2008; 28:210–217.

46

Cohort studies evaluating the association of Pre and Post dialysis BP
recordings with mortality and clinical outcomes among dialysis patients
47

Cohort studies evaluating the association of intradialytic change in BP with
mortality and clinical outcomes among dialysis patients
48
Panagiotis I. Georgianos1 and Rajiv Agarwa. American Journal of Hypertension 30(3) March 2017. 211-221

Cohort studies evaluating the association of out-of-dialysis BP recordings with
mortality and clinical outcomes among dialysis patients
49

Cohort studies evaluating the association of predialysis/postdialysis BP with
mortality and clinical outcomes among prevalent dialysis patients
50

Ambulatory BP monitoring
• Gold standard.
• Recommend whole interdialytic period. 44 hours.
• Better correlated with LVH.
52
Mansoor GA,WhiteWB: Ambulatory blood pressure monitoring is a useful clinical tool in nephrology.
Am J Kidney Dis 30: 591– 605, 1997
Peixoto AJ, Santos SF, Mendes RB, Crowley ST, Maldonado R, Orias M, Mansoor GA, White WB:
Reproducibility of ambulatory blood pressure monitoring in hemodialysis patients. Am J Kidney Dis 36:
983–990, 2000

Home BP measurement
• BP is lower post dialysis day.
• Increase 4 mmHg every 10 hours thereafter.
• Highest Predialysis day.
Recommended:
• Twice daily, early morning and before bedtime after mid week HD.
• Target 140/90 mmHg is a reasonable goal.
53
Agarwal R, Light RP: Chronobiology of arterial hypertension in hemodialysis patients: Implications for home blood pressure monitoring. Am J Kidney Dis
54: 693–701, 2009
Agarwal R, AndersenMJ, Light RP: Location not quantity of blood pressure measurements predicts mortality in hemodialysis patients. Am J Nephrol 28: 210–217,
2008
Agarawal R,. Et al. Assessment and Management of Hypertension in Patients on Dialysis. J Am Soc Nephrol 25: 1630–1646, 2014

Interdialytic 44 Hour ABPM & 6 measurement of BP
Over a mean follow-up of 24 months,
HRs for all-cause mortality per 10/5mmHg increase BP
44 H ABPM 1.22/1.18
6 BP measurement 1.20/1.15 when 6 BP
ABPM were randomly selected and averaged.
54
Agarwal R, Andersen MJ, Light RP. Location not quantity of blood pressure measurements predicts
mortality in hemodialysis patients. Am J Nephrol 2008; 28:210–217.

Home BP measurement
• Correlate more closely with Ambulatory BP.
• Can tract changes in BP evoked by the reduction in dry wt.
• Much more producible, one week to the next.
• Superior to dialysis measurement.
55
Agarwal R, Andersen MJ, Bishu K, Saha C: Home blood pressure monitoring improves the diagnosis of hypertension in hemodialysis patients. Kidney Int 69:
900–906, 2006
Agarwal R, Satyan S, Alborzi P, Light RP, Tegegne GG, Mazengia HS, Yigazu PM: Home blood pressure measurements for managing hypertension in
hemodialysis patients. Am J Nephrol 30: 126–134, 2009
Agarwal R, Brim NJ, Mahenthiran J, AndersenMJ, SahaC:Out-of-hemodialysis unit blood pressure is a superior determinant of left ventricular hypertrophy.
Hypertension 47: 62–68, 2006

Home BP measurement
• Significant drop in interdialytic ABPM over 6 month by using
Home versus Predialysis BP measurement.
• Improvement in the average weekly SBP was seen in the home
BP group.
56
da Silva GV, de Barros S, Abensur H,Ortega KC, Mion D Jr; Cochrane Renal Group Prospective Trial Register: CRG060800146: Home blood pressure
monitoring in blood pressure control among haemodialysis patients: An open randomized clinical trial. Nephrol Dial Transplant 24: 3805–3811,2009
Kauric-Klein Z, Artinian N: Improving blood pressure control in hypertensive hemodialysis patients. CANNT J 17: 24–28, 31–36, quiz 29–30, 37–38, 2007

Home Systolic BP and CV death in dialysis patients
• No association between Predialysis systolic BP and CVD death.
• Strong correlation between Home BP and CVD death. From
multiple BP reading at home.
• Out of dialysis unit SBP has a stronger correlated than unit SBP
with subclinical CVD as LVH. Assessed by 44 hours ABPM. Three
days BP.
Alborzi P, Patel N, Agarwal R. Home blood pressures are of greater prognostic value than hemodialysis unit recordings. Clin J Am Soc Nephrol. 2007;
2:1228–1234. [PubMed: 17942773]
Agarwal R, Brim NJ, Mahenthiran J, Andersen MJ, Saha C. Out-of-hemodialysis-unit blood pressure is a superior determinant of left ventricular hypertrophy.
Hypertension. 2006; 47:62–68. [PubMed: 16344376]
57

Central BP measuring Devices
58
https://atcormedical.com/technology/sphygmocor-pulse-wave-analysis/ https://www.numed.co.uk/products/mobil-o-graph-pwa

59
Aortic Pressure
SYSTOLE SYSTOLE
DIASTOLE

61
• Arterial system is a closed system
• Primary wave (blue) travels along
the arteries generating reflected
waves from bifurcations
• These small reflected waves return
to the heart, summing to create a
reflected pressure wave as shown in
grey, starting even before the end
of systole
Figure 2
Physiology - Pressure Wave Reflection at the Heart
JAFAR ALSAID, M.B.CHB.MD. FASN. FACP

64

65
ESC Stockholm. Central blood Pressure. To the heart of matter Sept 2010

Central BP performs better than the Brachial BP in
terms of CV mortality and outcome.
McEniery CM, Yasmin, McDonnell B, Munnery M, Wallace SM, Rowe CV, et al. Central pressure: variability and impact of cardiovascular risk factors. The Anglo-Cardiff Collaborative Trial II. Hypertension 2008;51:1476–82.
Townsend RR, Wimmer NJ, Chirinos JA, Parsa A, Weir M, Perumal K, et al. Aortic PWV in chronic kidney disease: a CRIC ancillary study. Am J Hypertens 2010;23:282–9.
Roman MJ, Devereux RB, Kizer JR, Lee ET, Galloway JM, Ali T, et al. Central pressure more strongly relates to vascular disease and outcome thandoes brachial pressure: the Strong Heart Study. Hypertension 2007;50:197–203.
Roman MJ, Devereux RB, Kizer JR, Okin PM, Lee ET, Wang W, et al. High central pulse pressure is independently associated with adverse cardiovascular outcome: the strong heart study. J Am Coll Cardiol 2009;54: 1730–4.
Pini R, Cavallini MC, Palmieri V, Marchionni N, Di BM, Devereux RB, et al. Central but not brachial blood pressure predicts cardiovascular events in an unselected geriatric population: the ICARe Dicomano Study. J Am Coll Cardiol
2008;51:2432–9.
Wang KL, Cheng HM, Sung SH, Chuang SY, Li CH, Spurgeon HA, et al.Wave reflection and arterial stiffness in the prediction of 15-year all-cause and cardiovascular mortalities: a community-based study. Hypertension 2010;55:799–805.
Mitchell GF, Hwang SJ, Vasan RS, Larson MG, Pencina MJ, Hamburg NM, et al. Arterial stiffness and cardiovascular events: the Framingham Heart Study. Circulation 2010;121:505–11.
66

Central BP performs better than the Brachial BP in
terms of CV mortality and outcome.
McEniery CM, Yasmin, McDonnell B, Munnery M, Wallace SM, Rowe CV, et al. Central pressure: variability and impact of cardiovascular risk factors. The Anglo-Cardiff
Collaborative Trial II. Hypertension 2008;51:1476–82.
Townsend RR, Wimmer NJ, Chirinos JA, Parsa A, Weir M, Perumal K, et al. Aortic PWV in chronic kidney disease: a CRIC ancillary study. Am J Hypertens 2010;23:282–9.
Roman MJ, Devereux RB, Kizer JR, Lee ET, Galloway JM, Ali T, et al. Central pressure more strongly relates to vascular disease and outcome thandoes brachial pressure: the
Strong Heart Study. Hypertension 2007;50:197–203.
Roman MJ, Devereux RB, Kizer JR, Okin PM, Lee ET, Wang W, et al. High central pulse pressure is independently associated with adverse cardiovascular outcome: the strong
heart study. J Am Coll Cardiol 2009;54: 1730–4.
Pini R, Cavallini MC, Palmieri V, Marchionni N, Di BM, Devereux RB, et al. Central but not brachial blood pressure predicts cardiovascular events in an unselected geriatric
population: the ICARe Dicomano Study. J Am Coll Cardiol 2008;51:2432–9.
Wang KL, Cheng HM, Sung SH, Chuang SY, Li CH, Spurgeon HA, et al.Wave reflection and arterial stiffness in the prediction of 15-year all-cause and cardiovascular mortalities:
a community-based study. Hypertension 2010;55:799–805.
Mitchell GF, Hwang SJ, Vasan RS, Larson MG, Pencina MJ, Hamburg NM, et al. Arterial stiffness and cardiovascular events: the Framingham Heart Study. Circulation
2010;121:505–11.
67

68

69

157
80 78
105
140
83
57
108
0
20
40
60
80
100
120
140
160
180
Systolic Diastolic Pulse Pressure MAP
Periperhal Central
**
**
**
**
**= p< 0.001
71
N = 14
HD sessions 33
Total readings 326/356
Al-Said J, Suyao C. Central Systolic and Diastolic Blood Pressure Pressures during Hemodialysis. Saudi J Kidney Dis Transpl 2021;32:170-3
Mean systolic, diastolic, MAP and pulse pressure for central and peripheral BP during Hemodialysis

Dialysis Ultrafiltration.
73
Intracellular
Interstitial
Intravascular
Wt: 70 Kg
Total Fluid 46.2L
Extracellular 15.2L
Intravascular space 3.8 L

Monthly Predialysis Na level for hemodialysis patients
Jan. – Sept 2023

BP
Temp.
Na
Time
UF
75
Hemodynamic stability

Increasing Quartiles of systolic BP subgroups
with ABPM and Home BP.
Hazard Ratio of increased risk of all cause mortality
Q1, Q2 & Q3
44H ABPM 2.5, 3.4 & 2.6
Home BP 2.1, 1.7 & 1.4
After multivariate adjustment.
BP within dialysis did not have any significant prognostic benefit.
76

Hazard Ratios for All-Cause Mortality by Quartiles of Wake and
Sleep Ambulatory Systolic BP

Therapeutic Indications and
recommendation
78

KDOQI BP guidelines
2005
•Predialysis BP < 140/90mmHg.
•Post Dialysis BP < 130/80 mmHg.
79
K/DOQI Workgroup: K/DOQI clinical practice guidelines for cardiovascular
disease in dialysis patients. Am J Kidney Dis 45[Suppl 3]: S1–S153, 2005

High BP and Mortality among ESRD patient
• Pre and post dialysis has an inverse relation with mortality,
REVERSE EPIDEMIOLOGY OF HTN AMONGE DIALYSIS.
• Out of dialysis BP carry direct relation with Mortality.
80
Panagiotis I. Georgianos and Rajiv Agarwal. Pressure and Mortality in Long-Term
Hemodialysis—Time to Move Forward. American Journal of Hypertension 30(3) March 2017.
211-222

81

82

Associations of systolic blood pressure (SBP) with mortality. The smooth spline estimates the
hazard ratio of all-cause mortality, according to systolic blood pressure (mm Hg) among CRIC
participants with SBP measured at (1) eGFR<30 ml/min/1.73 m2
No difference was found between systolic BP with mortality in
eGFR <30ml/min
All analyses are
adjusted for age,
gender,
race/ethnicity,
tobacco use,
BMI, diabetes,
history of
cardiovascular
disease.
83
eGFR < 30 not on dialysis
Bansal N, McCulloch C, Rahman M. et.al. Blood pressure and risk of all cause mortality in advanced chronic kidney disease and
hemodialysis: the CRIC study. Hypertension. 2015 Jan: 65(1): 93-100

ratio of all-cause mortality, according to systolic blood pressure (mm Hg) among CRIC participants
with SBP measured at Dialysis.
All analyses are
adjusted for age,
gender,
race/ethnicity,
tobacco use,
BMI, diabetes,
history of
cardiovascular
disease.
U shaped curve for the dialysis systolic BP measured at the start of
dialysis session
84
Hemodialysis patient with Intradialytic systolic BP
Bansal N, McCulloch C, Rahman M. et.al. Blood pressure and risk of all cause mortality in advanced chronic kidney disease and
hemodialysis: the CRIC study. Hypertension. 2015 Jan: 65(1): 93-100

hazard ratio of all-cause mortality, according to systolic blood pressure (mm Hg) among CRIC
participants with SBP for patient on dialysis measured out of dialysis.
All analyses are
adjusted for age,
gender,
race/ethnicity,
tobacco use,
BMI, diabetes,
history of
cardiovascular
disease.
Exponential elevation in the Mortality hazard by increasing SBP
85
Hemodialysis patient with out of dialysis systolic BP
Bansal N, McCulloch C, Rahman M. et.al. Blood pressure and risk of all cause mortality in advanced
chronic kidney disease and hemodialysis: the CRIC study. Hypertension. 2015 Jan: 65(1): 93-100

Diastolic BP and CV risk
• U shaped association between dialysis unit diastolic
BP and CV risk.
• No association was noticed between out of dialysis
unit diastolic BP and CV risk.
Hypertension. 2017 August ; 70(2): 435–443. doi:10.1161/HYPERTENSIONAHA.117.09091
86

Pulse Pressure and CV risk
• No correlation was noticed between dialysis unit Pulse
pressure and CV risk.
• There was a strong linear correlation between Out of
dialysis Pulse pressure and risk of CV disease.
Hypertension. 2017 August ; 70(2): 435–443. doi:10.1161/HYPERTENSIONAHA.117.09091
87

Hypertension Treatment
Among ESRD
88

Lifestyle Pharmacological
89
Management of HTN among ESRD
HTN

Goal of Anitihypertensive Therapy in CKD
90
Reduced
CV risk
Slow Kidney
disease
Decrease
BP
KDOQI 2014
http://kidneyfoundation.cachefly.net/professionals/KDOQI/guidelines

Management of HTN among ESRD
Non pharmacological :
• Exercise.
• Low Na diet. Of 1.5gm daily.
• Adjust the Dialysate Na bath.
• Management of dry wt.
• Adjustment of the dialysis time.
91

Target BP management in ESRD on HD
Home BP systolic 125-145mmHg
Ambulatory systolic 115-125 mmHg
Home BP systolic 120-130mmHg
Ambulatory systolic 110-120 mmHg
Alborzi P, Patel N, Agarwal R. Home blood pressures are of greater prognostic value than hemodialysis unit recordings. Clin J Am Soc Nephrol.
2007; 2:1228–1234. [PubMed: 17942773]
• Agarwal R, Brim NJ, Mahenthiran J, Andersen MJ, Saha C. Out-of-hemodialysis-unit blood pressure is a superior determinant of left
ventricular hypertrophy. Hypertension. 2006; 47:62–68. [PubMed: 16344376]
• Agarawal R. Blood Pressure and mortality among hemodialysis patients. Hypertnesion 2010;55:762-8

Dry Weight
Minimal tolerated Post dialysis Wt. Achieved
gradually at which there will be minimal signs
and symptoms of Hypovolemia or Hypervolemia.
93
Agarawal R., et. Al. Assessment and Management of Hypertension in Patients on Dialysis. J Am Soc
Nephrol 25: 1630–1646, 2014. doi: 10.1681/ASN.2013060601

Effect of Ultrafiltration of BP
• RCT.
• 150 HD patients. 100 intervention
50 control
• Exclude obvious Volume overload.
• Interdialytic Ambulatory BP monitoring.
• BP reduced in 4 week by 11/6 mmHg.
94
Agarwal R, Alborzi P, Satyan S, Light RP: Dry-weight reduction in
hypertensive hemodialysis patients (DRIP): A randomized,
controlled trial. Hypertension 53: 500–507, 2009.

Dialysis Ultrafiltration.
95
Intracellular
Interstitial
Intravascular
Wt: 70 Kg
Total Fluid 46.2L
Extracellular 15.2L
Intravascular space 3.8 L

BP
Temp.
Na
Time
UF
96
Hemodynamic stability

Dry wt. Achievement
with gradual UF increment by 0.5 Liter per session
• symptoms
• Clinical exam.
• Ultrasound. IVC, lung
• Plasma volume measurement and bioimpedance
devices.
• BNP

98
Kim T., Chang T., Kim T. et. al. Association of UF rate with mortality in incident HD patients. Nephron 2018;139(1):13-22.
Association of UF rate with mortality in incident HD patients

Managing Dry Wt.
• Achieving the dry wt.
• Gradual reduction of Post dialysis Wt. By 0.2 - 0.3 Kg.
• Edema, Inferior Vena cava, Blood volume are inaccurate determinants
of the volume status.
• Reduce BP, Improve Diastolic and Systolic cardiac function and reduce
LVH.
99
Agarwal R, Andersen MJ, Pratt JH: On the importance of pedal edema in hemodialysis patients. Clin J Am Soc
Nephrol 3: 153– 158, 2008
Agarwal R, Alborzi P, Satyan S, Light RP: Dry-weight reduction in hypertensive hemodialysis patients (DRIP): A
randomized, controlled trial. Hypertension 53: 500–507, 2009

Interdialytic Volume gain and BP
• Access Interdialytic Wt. gain Is associated with High BP.
• Removal of larger UF volume is associated with
hypotension, and larger fluid gain.
100
Inrig JK, Patel UD, Gillespie BS, Hasselblad V, Himmelfarb J, Reddan D, Lindsay RM, Winchester JF, Stivelman J, Toto
R, Szczech LA: Relationship between interdialytic weight gain and blood pressure among prevalent hemodialysis
patients. Am J Kidney Dis 50: 108–118, 2007
26. Agarwal R: Volume-associated ambulatory blood pressure patterns in hemodialysis
patients. Hypertension 54: 241–247, 2009

Hazards of Probing for Dry Wt.
• Increased access clotting.
• Decreased residual renal
function.
• Increased
hypotension/hypoperfusion.
101
Agarwal R, Alborzi P, Satyan S, Light RP: Dry-weight reduction in hypertensive hemodialysis patients (DRIP): A randomized,
controlled trial. Hypertension 53: 500–507, 2009

Plasma volume monitoring
• Reduce Admission, Improve BP control and decrease Hypotension.
(CLIMB) Crit-Line Intradialytic Monitoring Benefit;
• RCT, 6 months.
• N 227 with RPV and 216 Control.
• Results:
• Intervention caused 1.6 RR of Hospitalization. & 1.8 RR of Mortality.
102
Goldstein SL, Smith CM, Currier H: Noninvasive interventions to decrease hospitalization and associated costs for
pediatric patients receiving hemodialysis. J Am Soc Nephrol 14: 2127–2131, 2003
Rodriguez HJ, Domenici R, Diroll A, Goykhman I: Assessment of dry weight by monitoring changes in blood volume
during hemodialysis using Crit-Line. Kidney Int 68: 854–861, 2005
Reddan DN, Szczech LA, Hasselblad V, Lowrie EG, Lindsay RM, Himmelfarb J, Toto RD, Stivelman J, Winchester JF,
Zillman LA, Califf RM, Owen WF Jr: Intradialytic blood volume monitoring in ambulatory hemodialysis patients: A
randomized trial.JAmSoc Nephrol 16: 2162–2169, 2005

KDOQI 2014
http://kidneyfoundation.cachefly.net/professionals/KDOQI/guidelines
103

Effect of deliberate blood pressure (BP) lowering with antihypertensive drug therapy on
cardiovascular events among patients on dialysis.
104

Out of Dialysis BP target should be used to
treat HD patients rather than pre or post
dialysis BP.
• Alborzi P, Patel N, Agarwal R. Home blood pressures are of greater prognostic value than
hemodialysis unit recordings. Clin J Am Soc Nephrol. 2007; 2:1228–1234. [PubMed: 17942773]
• Agarwal R, Brim NJ, Mahenthiran J, Andersen MJ, Saha C. Out-of-hemodialysis-unit blood pressure is
a superior determinant of left ventricular hypertrophy. Hypertension. 2006; 47:62–68. [PubMed:
16344376]
105

Lower systolic BP during HD <140 mmHg is
associated with harm in HD patients
• Agarwal R. Blood pressure and mortality among hemodialysis patients. Hypertension. 2010; 55:762–768. [PubMed: 20083728]
• Kalantar-Zadeh K, Block G, Humphreys MH, Kopple JD. Reverse epidemiology of cardiovascular risk factors in maintenance dialysis
patients. Kidney Int. 2003; 63:793–808. [PubMed: 12631061]
• Zager PG, Nikolic J, Brown RH, Campbell MA, Hunt WC, Peterson D, Van Stone J, Levey A, Meyer KB, Klag MJ, Johnson HK, Clark E,
Sadler JH, Teredesai P. “U” curve association of blood pressure and mortality in hemodialysis patients. Medical directors of dialysis clinic,
inc. Kidney Int. 1998; 54:561–569. [PubMed: 9690224]
• Robinson BM, Tong L, Zhang J, Wolfe RA, Goodkin DA, Greenwood RN, Kerr PG, Morgenstern H, Li Y, Pisoni RL, Saran R, Tentori F, Akizawa
T, Fukuhara S, Port FK. Blood pressure levels and mortality risk among hemodialysis patients in the dialysis outcomes and practice
patterns study. Kidney Int. 2012; 82:570–580. [PubMed: 22718187]
• Port FK, Hulbert-Shearon TE, Wolfe RA, Bloembergen WE, Golper TA, Agodoa LY, Young EW. Predialysis blood pressure and mortality risk
in a national sample of maintenance hemodialysis patients. Am J Kidney Dis. 1999; 33:507–517. [PubMed: 10070915]
• Bansal N, McCulloch CE, Rahman M, et al. Blood pressure and risk of all-cause mortality in advanced chronic kidney disease and
hemodialysis: The chronic renal insufficiency cohort study. Hypertension. 2015; 65:93–100. [PubMed: 25287404]
• Feldman HI, Appel LJ, Chertow GM, et al. The chronic renal insufficiency cohort (cric) study: Design and methods. J Am Soc Nephrol.
2003; 14:S148–153. [PubMed: 12819321]
106

Adjustment of the Dialysate Na bath
• Lower Na bath cause decreased BP.
• Increased Na bath leads to increased Thirst, interdialytic volume, and BP.
• Combining Na control and Ultrafiltrate was able to control the HTN and BP.
107
Manlucu J, Gallo K, Heidenheim PA, Lindsay RM: Lowering postdialysis plasma sodium (conductivity) to increase
sodium removal in volume-expanded hemodialysis patients: A pilot study using a biofeedback software system. Am
J Kidney Dis 56: 69– 76, 2010
Barré PE, Brunelle G, Gascon-Barré M: A randomized double blind trial of dialysate sodiums of 145 mEq/L, 150mEq/L,
and 155 mEq/L. ASAIO Trans 34: 338–341, 1988
Munoz Mendoza J, Sun S, Chertow GM, Moran J, Doss S, Schiller B: Dialysate sodium and sodium gradient in
maintenance
Davies S, Carlsson O, Simonsen O, Johansson AC, Venturoli D, Ledebo I, Wieslander A, Chan C, Rippe B: The effects
of low-sodium peritoneal dialysis fluids on blood pressure, thirst and volume status. Nephrol Dial Transplant 24: 1609–
1617, 2009

September 2023 OKC and Luling HD patients

Monthly Predialysis Na level for hemodialysis patients
Jan. – Sept 2023

Achieving Dry Wt.
• Gradual reduction in Wt by 0.2-0.3 Kg and monitoring for early
hypovolemic symptoms.
• Adjustment of Dialysis time.
110
Agarawal R., et. Al. Assessment and Management of Hypertension in
Patients on Dialysis. J Am Soc Nephrol 25: 1630–1646, 2014. doi: 10.1681/ASN.2013060601

Duration of Dialysis and Frequency
• Increased treatment time or frequency is associated with
better BP.
• Nocturnal dialysis Improved BP and LVH. Reduced Anti HTN
medications.
111
Tattersall J, Martin-Malo A, Pedrini L, Basci A, Canaud B, FouqueD, Haage P, Konner K, Kooman J, Pizzarelli F, Tordoir
J, Vennegoor M, Wanner C, ter Wee P, Vanholder R: EBPG guideline on dialysis
strategies. Nephrol Dial Transplant 22 [Suppl 2]: ii5–ii21, 2007
Chan CT, Floras JS, Miller JA, Richardson RM, Pierratos A: Regression of left ventricular hypertrophy after conversion
to nocturnal hemodialysis. Kidney Int 61: 2235–2239, 2002

HTN among PD patients
Patients with higher membrane transporter have volume
over load and higher BP.
112
Tonbul Z, Altintepe L, Sözlü C, Yeksan M, Yildiz A, Türk S: The association of peritoneal
transport properties with 24-hour blood pressure levels in CAPD patients. Perit Dial Int 23: 46–52, 2003

HTN control among PD patients as compared to HD
• BP is better controlled with PD as compared to HD.
• With better volume control.
• Wash out of vasopressors and Na Pump inhibitors.
113
Boudville NC, Cordy P,Millman K, Fairbairn L, Sharma A, Lindsay R, Blake PG: Blood pressure, volume, and sodium control in an automated
peritoneal dialysis population. Perit Dial Int 27: 537–543, 2007.
Velasquez MT, Lew SQ, von Albertini B, Mishkin GJ, Bosch JP: Control of hypertension is better during hemodialysis than during continuous
ambulatory peritoneal dialysis in ESRD patients. Clin Nephrol 48: 341–345, 1997.
Weiler EWJ, Saldanha LF, Khalil-Manesh F, Prins BA, Purdy RE,GonickHC: Relationship of Na-K-ATPase inhibitors to blood-pressure
regulation in continuous ambulatory peritoneal dialysis and hemodialysis. J Am Soc Nephrol 7: 454–463, 1996

Drug Management
• Water or Lipid soluble drugs.
• Increase action in ESRD.
• Dialyzable drugs.
• Pharmacodynamics of the drugs.
114
Nissenson A., Fine R. Elsevier. 5th Edition. Hand Book of dialysis. The Challenges of BP control
in Dialysis Patients. 2017.

Pharmacokinetic Property of some AntiHTN medications
Drug Protein Bound
%
Half life/
in ESRD (h)
Change dose
in ESRD
(% less)
(%) Removed
with (HD /PD)
Clonidine 20-40 5-13 / 17-40 50 -75 5% / NA
Methyldopa < 20 1-2 / 1.7 – 3.6 12 -24 60 / 30-40
Doxazosin 98-99 10 -15 same None None/NA
Atenolol 10 6-9 / <120 75 53 /48
Bisoprolol 30 14-22 / 28-44 50 25-35/None
Carvedilol 95 4-7 same None None
Labetalol PO 50 3.4 same Slight <1
Enalapril High 11 /Prolonged Yes 35/NA
Lisinopril 3-10 12.7 /54.3 75 50 / NA
Valsartan 95 6 NA None
Perindopril 60 3-10/ slightly 41-76 50
Amlodipine 97% 30-50 / 40-60 None NA
115
Nissenson A., Fine R. Elsevier. 5th Edition. Hand Book of dialysis. The Challenges of BP control in Dialysis
Patients. 2017.

Betablockers
Hemodialysis Patients treated with Atenolol versus Lisinopril
(HDPAL);
• RCT with 200 HD.
• target BP <140/90mmHg. With Atenolol or Lisinopril.
• Atenolol was superior.
• Heart failure, Stroke and MI were more among Lisinopril arm
17% compared to 11% P 0.02.
116
Agarwal R, Sinha AD: Cardiovascular protection with antihypertensive drugs in dialysis patients: Systematic review and
meta-analysis. Hypertension 53: 860–866, 2009

Betablocker
117
• Selective B1, Non selective and Alpha/ Beta Antagonists.
• Lipid solubility
• Intrinsic Sympathomimetic activity.
Side effects: Bradycardia.
Bronchospasm.
Peripheral vascular disease.
Nebivolol Stim. Nitric Oxide Production. Cause vasodilatation.
Carvedilol preferable and stable levels with dialysis.
Patients. 2017.

Calcium Channel Blocker
Dihydropyridine. Edema.
Non Dihydropyridine.
Cause Negative Inotropic and Chronotropic effect.
Nifedipine: Sympathetic stimulation.
not one of the first options.
118

RAAS
Recommended in CKD.
Compelling indications.
Potassium.
Anaphylaxis with AN 69
119

Diuretics
• Loop Diuretics.
• Thiazides?
• Side effects.
• Residual renal function.
120
Hörl MP, Hörl WH: Drug therapy for hypertension in hemodialysis patients. Semin Dial 17: 288–294, 2004
Hayashi SY, Seeberger A, Lind B, Gunnes S, Alvestrand A, do Nascimento MM, Lindholm B, Brodin LA:
Acute effects of low and high intravenous doses of furosemide on myocardial function in anuric
haemodialysis patients: A tissue Doppler study. Nephrol Dial Transplant 23: 1355–1361, 2008

Diuretics:
Loop Diuretic is required when eGFR below 40-30%.
Mineralocorticoids:
• Have CV benefit.
• Used in CKD and even ESRD.
• Improved EF in Heart Failure.
• Hyperkalemia.
• Dose adjustment is needed.
121
Specific consideration for AntiHTN
medications in ESRD patients
Nissenson A., Fine R. Elsevier. 5th Edition. Hand Book of dialysis. The Challenges of BP control in Dialysis Patients. 2017.

Mineralocorticoids
• Have CV benefit.
• Used in CKD and even ESRD.
• Improved EF in Heart Failure.
• Hyperkalemia.
• Dose adjustment is needed.
122

• Loop Diuretics in HD with very low eGFR are ineffective.
• Higher ototoxicity in large dose.
• More studies on residual renal function.
123
Medications in Treating HTN
Hörl MP, Hörl WH: Drug therapy for hypertension in hemodialysis patients. Semin Dial 17: 288–294, 2004
Hayashi SY, Seeberger A, Lind B, Gunnes S, Alvestrand A, do Nascimento MM, Lindholm B, Brodin LA:
Acute effects of low and high intravenous doses of furosemide on myocardial function in anuric
haemodialysis patients: A tissue Doppler study. Nephrol Dial Transplant 23: 1355–1361, 2008

Betablocker:
• Lipid solubility
• Intrinsic Sympathomimetic activity.
• Selective B1, Non selective and Alpha/ Beta Antagonists. Stim and
• Reduced Heart rate, Myocardial contractility and AV conduction. With
reduced Cardiac output.
• Superior in Heart Failure and IHD.
• May cause Peripheral Vasoconstriction.
• Bronchospasm.
• Nebivolol which Stim. Nitric Oxide Production. Cause vasodilatation.
• Carvedilol has preferable and stable levels with dialysis.
124
Patients. 2017.

ACE inh.
• Cough or Angioedema.
• Worsening of Anemia.
• Anaphylaxis with AN 69 Dialysis Membrane.
Calcium channel Blocker:
Dihydropyridine. Edema.
Non Dihydropyridine. Cause Negative Inotropic and Chronotropic effect.
Nifedipine: Not recommended to be used.
125
Nissenson A., Fine R. Elsevier. 5th Edition. Hand Book of dialysis. The Challenges of BP control in Dialysis Patients. 2017.

Medications in Treating HTN
• RAAS are the first line recommended because of their CV benefit.
Hemodialysis Patients treated with Atenolol versus Lisinopril (HDPAL);
• RCT with 200 HD.
• Randomized to target BP <140/90mmHg. With Atenolol or Lisinopril.
• Atenolol was superior.
• Heart failure, Stroke and MI were more among Lisinopril arm
• 17% compared to 11% P 0.02.
126
Zannad F, Kessler M, Lehert P, Grünfeld JP, Thuilliez C, Leizorovicz A, Lechat P: Prevention of cardiovascular events in endstage renal
disease: Results of a randomized trial of fosinopril and implications for future studies. Kidney Int 70: 1318–1324, 2006
Takahashi A, Takase H, Toriyama T, Sugiura T, Kurita Y, Ueda R, Dohi Y: Candesartan, an angiotensin II type-1 receptor blocker, reduces
cardiovascular events in patients on chronic haemodialysis—a randomized study. Nephrol Dial Transplant 21: 250
Agarwal R, Sinha AD: Cardiovascular protection with antihypertensive drugs in dialysis patients: Systematic review and
meta-analysis. Hypertension 53: 860–866, 2009

Paradoxical Intradialytic Hypertension
• 10-15 % of dialysis patients.
• Increase BP by in the post dialysis more than Predialysis.
• Carries higher 6 months mortality.
• Association with volume and Interdialytic HTN was suggested.
• Dry Wt. Challenge was effective in studies to reduce the BP.
127
Inrig JK: Intradialytic hypertension: A lessrecognized cardiovascular complication of hemodialysis. Am J Kidney Dis 55: 580– 589, 2010.
Chou KJ, Lee PT, Chen CL, Chiou CW, Hsu CY, Chung HM, Liu CP, Fang HC: Physiological changes during hemodialysis in patients with intradialysis hypertension. Kidney Int 69: 1833–1838, 2006
CiritM, Akçiçek F, Terzioglu E, Soydasx C, Ok E, Ozbasxli CF, Basxçi A, Mees EJ: ‘Paradoxical’ rise in blood pressure during ultrafiltration in dialysis patients. Nephrol Dial Transplant 10: 1417–
1420, 1995
Agarwal R, Alborzi P, Satyan S, Light RP: Dry-weight reduction in hypertensive hemodialysis patients (DRIP): A randomized, controlled trial. Hypertension 53: 500–507, 2009
Lower dialysate Na.
Inrig JK, Molina C, D’Silca K, et al. Effect of low versus high Na concentration on BP nd endothelial derived vasoregulators during HD. A randomized cross over study. AM J Kidney Dis 2015; 65:464

Erythropoietin and HTN
Increased BP related to:
• Endothelin production and sensitivity.
• Increase BP response to Angiotensin II.
• Changing dose or using Subcutaneous Rout could reduce the effect.
128
Wang XQ, Vaziri ND: Erythropoietin depresses nitric oxide synthase expression by human endothelial cells. Hypertension 33: 894–899,
1999.
Carlini RG, Dusso AS, Obialo CI, Alvarez UM, Rothstein M: Recombinant human erythropoietin (rHuEPO) increases endothelin- 1 release
by endothelial cells. Kidney Int 43: 1010–1014, 1993
Eggena P, Willsey P, Jamgotchian N, Truckenbrod L, Hu MS, Barrett JD, Eggena MP, Clegg K, Nakhoul F, Lee DB: Influence of
recombinant human erythropoietin on blood pressure and tissue renin-angiotensin systems. Am J Physiol 261: E642–E646, 1991
Agarwal R. et. Al. ,* Joseph Flynn,† Velvie Pogue,‡ Mahboob Rahman,§ Efrain Reisin,| and Matthew R. Weir.Assessment and
Management of Hypertension in Patients on Dialysis. AmSoc Nephrol 25: 1630–1646, 2014

Sleep Apnea among HD patients
• Associated with High BP.
• Related to volume overload.
129
Park J, Campese VM: Resistant hypertension and obstructive sleep apnea in end-stage renal disease.
J Hypertens 30: 880–881, 2012
Tada T, Kusano KF, Ogawa A, Iwasaki J, Sakuragi S, Kusano I, Takatsu S,MiyazakiM, Ohe T: The
predictors of central and obstructive sleep apnea in haemodialysis patients.NephrolDial Transplant 22:
1190– 1197, 2007

Conclusion
• HTN is one of the common causes of CKD and ESRD.
• Managing BP is major part of looking after ESRD patients.
• Interdialytic (out of dialysis) BP is more reliable.
• 120-140 mmHg systolic is a target of Home BP
• 110-130 mmHg ambulatory Gradual Dry wt. adjustment.
• Dialysate Na. modulation.
• Look into selecting the proper Medications
130

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