Hypertension Management in Dialysis Patients

Hypertension is almost universal among patients with end-stage renal disease undergoing dialysis and represents a key driver of cardiovascular morbidity and mortality. Pathophysiological mechanisms include volume overload, sodium retention, increased arterial stiffness and heightened sympathetic activity. Management requires a multifaceted approach encompassing precise fluid removal through tailored ultrafiltration rates, preservation of residual renal function and strict dietary sodium restriction. Pharmacological interventions are selected according to comorbidities and residual urine output, with renin–angiotensin system blockers, β-blockers and, in those with maintained diuresis, loop diuretics forming the mainstays of therapy. Advances in home and ambulatory blood pressure monitoring have unveiled patterns of masked and white-coat hypertension, enabling more accurate risk stratification and individualised target setting. Contemporary research emphasises the need for patient-centred blood pressure goals that mitigate cardiovascular risk without provoking intradialytic hypotension. This precision medicine framework aims to harmonise volume control, antihypertensive drug therapy and patient empowerment to improve long-term outcomes in this vulnerable population.

Research from Nature Portfolio

Large observational studies have clarified the role of diuretics in incident dialysis cohorts, demonstrating that moderate loop diuretic exposure during the first two years of treatment is associated with reduced mortality compared to non-use, whereas prolonged high-dose exposure correlates with increased hospitalisation, likely reflecting chronic fluid overload despite preserved residual function. In parallel, analyses of predialysis systolic blood pressure targets have revealed a U-shaped association with all-cause mortality: both systolic values below 110 mmHg and above 170 mmHg confer elevated risk, while a predialysis range of approximately 120–140 mmHg optimises survival. These insights support an individualised approach to ultrafiltration prescriptions and antihypertensive regimens, tailored to dialysis modality, vintage and patient-specific cardiovascular risk profiles.

Hypertension Management in Dialysis Patients publication trend

The graph below shows the total number of articles in hypertension management in dialysis patients across all publications each year (not limited to Nature Index journals).

Technical terms

Hemodialysis: A renal replacement therapy in which blood is filtered through a semipermeable membrane to remove waste products and excess fluid.

Predialysis blood pressure: The patient’s blood pressure measured immediately before a dialysis session, guiding ultrafiltration and antihypertensive adjustments.

Ultrafiltration rate: The speed at which fluid is extracted during dialysis, calibrated to achieve euvolaemia without inducing hypotensive episodes.

Loop diuretics: Diuretic drugs that inhibit sodium and chloride reabsorption in the thick ascending limb of Henle’s loop, used when residual renal function permits fluid removal.

Ambulatory blood pressure monitoring: Continuous recording of blood pressure over 24 hours to detect hypertension variants, including nocturnal and masked hypertension.

References

1. Diuretics and mortality reduction in incident dialysis patients: a two-year observational study. Scientific Reports (2024).
2. The Optimal Blood Pressure Target in Different Dialysis Populations. Scientific Reports (2018).
3. Efficacy of a Web-Based Home Blood Pressure Monitoring Program in Improving Predialysis Blood Pressure Control Among Patients Undergoing Hemodialysis: Randomized Controlled Trial. JMIR mHealth and uHealth (2024).
4. Diuretic prescriptions in the first year of haemodialysis: international practice patterns and associations with outcomes. Clinical Kidney Journal (2024).
5. Influence of Different Types of β-Blockers on Mortality in Patients on Hemodialysis. Biomedicines (2023).