Hypertension in the hemodialysis population: A survey of
Am J Kidney Dis
(Sep) 26:461-468 1995
This is a descriptive study of blood pressures in 649 mostly (89%) black
patients in dialysis units in Mississippi. Patients were classified as
hypertensive if they were taking anti-hypertensive meds or if mean
MAP was greater than 114 mm Hg. Isolated systolic hypertension was defined
presystolic greater than 160 with a prediastolic BP less than 90. Patients
judged to be volume responsive if MAP decreased by more than 5% during
About 72% of the total population was hypertensive according to this
Of the hypertensives, about 80% were being treated, and 20% were not. BP
lower in patients more than 65 years of age. Hypertension was "volume
65% of cases, BP increased during dialysis in 9%, and BP was largely
in the remainder of patients. MAP fell by 10% in untreated hypertensives,
only by 7% in patients receiving one or more drugs. Predialysis BP was
in patients whose etiology of ESRD was hypertension, glomerulonephritis,
diabetes, and PCKD. Of the 40% hypertensives receiving monotherapy, 22% were
CCBs, 10% on vasodilators, 10% on sympatholytics, and 5% on ACE-inhibitors.
Pre-MAP was similar in these groups, and the ACE-group had similar
weight gains to the others (other data have suggested that ACE inhibitor
administration to thirsty patients with high renin levels mitigates thirst).
Comment: In the analyses, treated hypertensive patients were mixed
with untreated patients, thus, a chicken vs. egg question comes up with a
of the findings. In the abstract, the author implies that anti-
may not be effective, as BP was only 3 mm less in treated hypertensives than
untreated hypertensives. This is a flawed argument, as patient selection
play an important role (i.e., if the treated patients had not been treated,
their BP may have been much higher, with the presently untreated cohort
representing a mildly affected subgroup). A further point made is, that
the BP fell by only 7% in treated hypertensives vs. 10% in treated
hypertensives, volume is not an important component to the hypertension.
author also found, in agreement with Luik et al (Contrib Nephrol 106:90-93,
1994), that BP gain did not correlate with interdialytic weight gain. Yet,
of patients were volume responsive by the author's own definition, and the
adequacy of ultrafiltration is difficult to assess in dialysis patients.
Futhermore, volume overload per se may predispose to LVH independently of
level of blood pressure. This study does serve to focus attention on the
gravity of the problem of high BP in dialysis patients.
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