55-year-old gentleman with past medical history seen for hypertension, polycystic kidney disease and end-stage renal disease on dialysis for the past 4 years. He gets dialysis on a Monday Wednesday Friday schedule. Systolic blood pressure midweek on wednesday day during dialysis is 150 systolic range. His current blood pressure medications include metoprolol and amlodipine. Is currently on a 140 sodium bath with a 3-1/2-hour session of dialysis. Clinical examination shows evidence of bibasilar crackles, 1+ lower extremity edema and elevated JVD. He is not very compliant with a low-salt diet the next up in theManagement of this patient

Explanation:

Hypertension  in dialysis patients is due to  Volume expansion, sympathetic overactivity, activation of the renin-angiotensin system, and arteriosclerosis. self-recorded home blood pressure (BP) monitoring are efficient, accurate, and correlate with readings obtained by ambulatory blood pressure monitoring (ABPM) and can be used .to screen for hypertension. If home BP monitoring is unable to be performed,  median intradialytic BP can be used  to diagnose and treat hypertension. Indications for intervention include interdialytic self-recorded home BP that is >140/80 mmHg or a target midweek median intradialytic BP to >140/80 mmHg.  The most important way to improve BP in a dialysis patient is by reducing volume and achieve ideal  dry weight over days to weeks. A lower dialysate sodium concentration may result in  decreased BP . Higher serum sodium bath result in higher serum sodium values postdialysis , causing rise in volume overload and increased thirst.and higher interdialytic  weight gain. . The dialysate sodium should be reduced gradually (ie, 1 mEq/L every three to four weeks) to approximately 136 mEq/L.For most dialysis patients who are hypertensive despite achieving optimal dry weight,  beta blocker  are ideal I(. A randomized study has suggested that patients treated with atenolol have fewer major cardiovascular events compared with lisinopril)  Dihydropyridine calcium blockers , such as amlodipine are our second choice for patients who do not tolerate the beta blocker . If the combination of atenolol and a calcium blocker is not effective, next step is to add an angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB). Resistant HTN is treated with addition of methyldopa or aldactone.

References 

 

Agarwal R, Sinha AD, Pappas MK, et al. Hypertension in hemodialysis patients treated with atenolol or lisinopril: a randomized controlled trial. Nephrol Dial Transplant 2014; 29:672.

https://pubmed.ncbi.nlm.nih.gov/9041214/, Dialysate sodium delivery can alter chronic blood pressure management. AUFlanigan MJ, Khairullah QT, Lim VS SOAm J Kidney Dis. 1997;29(3):383. 

 

Case reviewed by Medcase editor

Designation: ABIM, BOARD CERTIFIED, NEPHROLOGY

univ of miami

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