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Hypertension in dialysis patients

Rajiv Agarwal, MD
William L Henrich, MD, MACP
Lionel U Mailloux, MD, FACP
Section Editors
Steve J Schwab, MD
George L Bakris, MD
Deputy Editor
Alice M Sheridan, MD


Hypertension is common among dialysis patients [1]. This topic reviews the epidemiology, pathogenesis, and treatment of hypertension in dialysis patients.

Hypertension among patients with acute or chronic kidney disease who are not on dialysis is discussed elsewhere. (See "Overview of hypertension in acute and chronic kidney disease" and "Antihypertensive therapy and progression of nondiabetic chronic kidney disease in adults".)

Hypertension in the general adult population is discussed elsewhere. (See "Overview of hypertension in adults" and "Choice of drug therapy in primary (essential) hypertension" and "What is goal blood pressure in the treatment of hypertension?".)


Hypertension is a common finding in dialysis patients. Prevalence estimates vary widely among studies because of differences in the definition of hypertension and in methods of measuring blood pressure (BP; ie, either before and after dialysis or using ambulatory BP recordings). Based upon multiple studies, over 50 to 60 percent of hemodialysis patients (up to 85 percent in some reports) and nearly 30 percent of peritoneal dialysis patients are hypertensive [2-6]. In one multicenter trial that included 2535 adult hemodialysis patients, the prevalence of hypertension, defined as one-week average predialysis systolic BP measurements 150 mmHg or diastolic BP 85 mmHg or the use of antihypertensive medications, was 86 percent [5,6].

Hypertension is more common among patients who are just initiating dialysis (greater than 80 percent) because almost all such patients are volume overloaded [7]. Persistent hypertension often reflects inadequate volume control despite the initiation of dialysis [4,8]. (See 'Pathogenesis' below.)

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Literature review current through: Nov 2017. | This topic last updated: Oct 14, 2016.
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  1. Mailloux LU, Haley WE. Hypertension in the ESRD patient: pathophysiology, therapy, outcomes, and future directions. Am J Kidney Dis 1998; 32:705.
  2. 1995 Annual Report. ESRD core indicators project. Opportunities to improve care for adult in-center hemodialysis patients. Health Care Financing Administration; DHHS, Baltimore, MD 1996.
  3. Rocco MV, Flanigan MJ, Beaver S, et al. Report from the 1995 Core Indicators for Peritoneal Dialysis Study Group. Am J Kidney Dis 1997; 30:165.
  4. Rahman M, Dixit A, Donley V, et al. Factors associated with inadequate blood pressure control in hypertensive hemodialysis patients. Am J Kidney Dis 1999; 33:498.
  5. Agarwal R, Nissenson AR, Batlle D, et al. Prevalence, treatment, and control of hypertension in chronic hemodialysis patients in the United States. Am J Med 2003; 115:291.
  6. Agarwal R, Flynn J, Pogue V, et al. Assessment and management of hypertension in patients on dialysis. J Am Soc Nephrol 2014; 25:1630.
  7. Zucchelli P, Santoro A, Zuccala A. Genesis and control of hypertension in hemodialysis patients. Semin Nephrol 1988; 8:163.
  8. Rahman M, Fu P, Sehgal AR, Smith MC. Interdialytic weight gain, compliance with dialysis regimen, and age are independent predictors of blood pressure in hemodialysis patients. Am J Kidney Dis 2000; 35:257.
  9. Argilés A, Lorho R, Servel MF, et al. Seasonal modifications in blood pressure are mainly related to interdialytic body weight gain in dialysis patients. Kidney Int 2004; 65:1795.
  10. Nongnuch A, Campbell N, Stern E, et al. Increased postdialysis systolic blood pressure is associated with extracellular overhydration in hemodialysis outpatients. Kidney Int 2015; 87:452.
  11. Salem MM. Hypertension in the hemodialysis population: a survey of 649 patients. Am J Kidney Dis 1995; 26:461.
  12. Fishbane S, Natke E, Maesaka JK. Role of volume overload in dialysis-refractory hypertension. Am J Kidney Dis 1996; 28:257.
  13. Lins RL, Elseviers M, Rogiers P, et al. Importance of volume factors in dialysis related hypertension. Clin Nephrol 1997; 48:29.
  14. Vertes V, Cangiano JL, Berman LB, Gould A. Hypertension in end-stage renal disease. N Engl J Med 1969; 280:978.
  15. Charra B, Calemard E, Ruffet M, et al. Survival as an index of adequacy of dialysis. Kidney Int 1992; 41:1286.
  16. Ozkahya M, Töz H, Unsal A, et al. Treatment of hypertension in dialysis patients by ultrafiltration: role of cardiac dilatation and time factor. Am J Kidney Dis 1999; 34:218.
  17. Günal AI, Duman S, Ozkahya M, et al. Strict volume control normalizes hypertension in peritoneal dialysis patients. Am J Kidney Dis 2001; 37:588.
  18. Hoenich NA, Levin NW. Can technology solve the clinical problem of 'dry weight'? Nephrol Dial Transplant 2003; 18:647.
  19. Aşci G, Ozkahya M, Duman S, et al. Volume control associated with better cardiac function in long-term peritoneal dialysis patients. Perit Dial Int 2006; 26:85.
  20. Agarwal R, Alborzi P, Satyan S, Light RP. Dry-weight reduction in hypertensive hemodialysis patients (DRIP): a randomized, controlled trial. Hypertension 2009; 53:500.
  21. Converse RL Jr, Jacobsen TN, Toto RD, et al. Sympathetic overactivity in patients with chronic renal failure. N Engl J Med 1992; 327:1912.
  22. Agarwal R, Light RP. Arterial stiffness and interdialytic weight gain influence ambulatory blood pressure patterns in hemodialysis patients. Am J Physiol Renal Physiol 2008; 294:F303.
  23. Georgianos PI, Agarwal R. Aortic Stiffness, Ambulatory Blood Pressure, and Predictors of Response to Antihypertensive Therapy in Hemodialysis. Am J Kidney Dis 2015; 66:305.
  24. Shichiri M, Hirata Y, Ando K, et al. Plasma endothelin levels in hypertension and chronic renal failure. Hypertension 1990; 15:493.
  25. Koyama H, Tabata T, Nishzawa Y, et al. Plasma endothelin levels in patients with uraemia. Lancet 1989; 1:991.
  26. Suzuki N, Matsumoto H, Miyauchi T, et al. Endothelin-3 concentrations in human plasma: the increased concentrations in patients undergoing haemodialysis. Biochem Biophys Res Commun 1990; 169:809.
  27. Vallance P, Leone A, Calver A, et al. Accumulation of an endogenous inhibitor of nitric oxide synthesis in chronic renal failure. Lancet 1992; 339:572.
  28. Raine AE, Bedford L, Simpson AW, et al. Hyperparathyroidism, platelet intracellular free calcium and hypertension in chronic renal failure. Kidney Int 1993; 43:700.
  29. Goldsmith DJ, Covic AA, Venning MC, Ackrill P. Blood pressure reduction after parathyroidectomy for secondary hyperparathyroidism: further evidence implicating calcium homeostasis in blood pressure regulation. Am J Kidney Dis 1996; 27:819.
  30. Desir GV. Regulation of blood pressure and cardiovascular function by renalase. Kidney Int 2009; 76:366.
  31. Gross ML, Ritz E. Hypertrophy and fibrosis in the cardiomyopathy of uremia--beyond coronary heart disease. Semin Dial 2008; 21:308.
  32. Siu AL, U.S. Preventive Services Task Force. Screening for high blood pressure in adults: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2015; 163:778.
  33. Agarwal R, Light RP. Chronobiology of arterial hypertension in hemodialysis patients: implications for home blood pressure monitoring. Am J Kidney Dis 2009; 54:693.
  34. Sankaranarayanan N, Santos SF, Peixoto AJ. Blood pressure measurement in dialysis patients. Adv Chronic Kidney Dis 2004; 11:134.
  35. Peixoto AJ, Santos SF, Mendes RB, et al. Reproducibility of ambulatory blood pressure monitoring in hemodialysis patients. Am J Kidney Dis 2000; 36:983.
  36. Agarwal R, Andersen MJ, Bishu K, Saha C. Home blood pressure monitoring improves the diagnosis of hypertension in hemodialysis patients. Kidney Int 2006; 69:900.
  37. 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.
  38. 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.
  39. Agarwal R. Blood pressure and mortality among hemodialysis patients. Hypertension 2010; 55:762.
  40. Agarwal R, Andersen MJ, Light RP. Location not quantity of blood pressure measurements predicts mortality in hemodialysis patients. Am J Nephrol 2008; 28:210.
  41. 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.
  42. Port FK, Hulbert-Shearon TE, Wolfe RA, et al. Predialysis blood pressure and mortality risk in a national sample of maintenance hemodialysis patients. Am J Kidney Dis 1999; 33:507.
  43. Zager PG, Nikolic J, Brown RH, et al. "U" curve association of blood pressure and mortality in hemodialysis patients. Medical Directors of Dialysis Clinic, Inc. Kidney Int 1998; 54:561.
  44. Agarwal R, Peixoto AJ, Santos SF, Zoccali C. Pre- and postdialysis blood pressures are imprecise estimates of interdialytic ambulatory blood pressure. Clin J Am Soc Nephrol 2006; 1:389.
  45. Agarwal R. How should hypertension be assessed and managed in hemodialysis patients? Home BP, not dialysis unit BP, should be used for managing hypertension. Semin Dial 2007; 20:402.
  46. Agarwal R. Managing hypertension using home blood pressure monitoring among haemodialysis patients--a call to action. Nephrol Dial Transplant 2010; 25:1766.
  47. Udayaraj UP, Steenkamp R, Caskey FJ, et al. Blood pressure and mortality risk on peritoneal dialysis. Am J Kidney Dis 2009; 53:70.
  48. Mailloux LU, Levey AS. Hypertension in patients with chronic renal disease. Am J Kidney Dis 1998; 32:S120.
  49. Locatelli F, Covic A, Chazot C, et al. Hypertension and cardiovascular risk assessment in dialysis patients. Nephrol Dial Transplant 2004; 19:1058.
  50. Takeda A, Toda T, Fujii T, et al. Discordance of influence of hypertension on mortality and cardiovascular risk in hemodialysis patients. Am J Kidney Dis 2005; 45:112.
  51. Heerspink HJ, Ninomiya T, Zoungas S, et al. Effect of lowering blood pressure on cardiovascular events and mortality in patients on dialysis: a systematic review and meta-analysis of randomised controlled trials. Lancet 2009; 373:1009.
  52. Agarwal R, Sinha AD. Cardiovascular protection with antihypertensive drugs in dialysis patients: systematic review and meta-analysis. Hypertension 2009; 53:860.
  53. http://www.heart.org/idc/groups/heart-public/@wcm/@hcm/documents/downloadable/ucm_300310.pdf.
  54. Schömig M, Eisenhardt A, Ritz E. Controversy on optimal blood pressure on haemodialysis: normotensive blood pressure values are essential for survival. Nephrol Dial Transplant 2001; 16:469.
  55. Li Z, Lacson E Jr, Lowrie EG, et al. The epidemiology of systolic blood pressure and death risk in hemodialysis patients. Am J Kidney Dis 2006; 48:606.
  56. Tentori F, Hunt WC, Rohrscheib M, et al. Which targets in clinical practice guidelines are associated with improved survival in a large dialysis organization? J Am Soc Nephrol 2007; 18:2377.
  57. Robinson BM, Tong L, Zhang J, et al. Blood pressure levels and mortality risk among hemodialysis patients in the Dialysis Outcomes and Practice Patterns Study. Kidney Int 2012; 82:570.
  58. Salem MM. Hypertension in the haemodialysis population: any relationship to 2-years survival? Nephrol Dial Transplant 1999; 14:125.
  59. Kalantar-Zadeh K, Kilpatrick RD, McAllister CJ, et al. Reverse epidemiology of hypertension and cardiovascular death in the hemodialysis population: the 58th annual fall conference and scientific sessions. Hypertension 2005; 45:811.
  60. Stidley CA, Hunt WC, Tentori F, et al. Changing relationship of blood pressure with mortality over time among hemodialysis patients. J Am Soc Nephrol 2006; 17:513.
  61. Goldwasser P, Avram MM, Collier JT, et al. Correlates of vascular access occlusion in hemodialysis. Am J Kidney Dis 1994; 24:785.
  62. Culp K, Flanigan M, Taylor L, Rothstein M. Vascular access thrombosis in new hemodialysis patients. Am J Kidney Dis 1995; 26:341.
  63. Chang TI, Paik J, Greene T, et al. Intradialytic hypotension and vascular access thrombosis. J Am Soc Nephrol 2011; 22:1526.
  64. Abu-Alfa AK, Burkart J, Piraino B, et al. Approach to fluid management in peritoneal dialysis: a practical algorithm. Kidney Int Suppl 2002; :S8.
  65. Agarwal R, Andersen MJ, Pratt JH. On the importance of pedal edema in hemodialysis patients. Clin J Am Soc Nephrol 2008; 3:153.
  66. Abraham PA, Opsahl JA, Keshaviah PR, et al. Body fluid spaces and blood pressure in hemodialysis patients during amelioration of anemia with erythropoietin. Am J Kidney Dis 1990; 16:438.
  67. Charra B, Laurent G, Chazot C, et al. Clinical assessment of dry weight. Nephrol Dial Transplant 1996; 11 Suppl 2:16.
  68. Sinha AD, Agarwal R. Can chronic volume overload be recognized and prevented in hemodialysis patients? The pitfalls of the clinical examination in assessing volume status. Semin Dial 2009; 22:480.
  69. Onofriescu M, Hogas S, Voroneanu L, et al. Bioimpedance-guided fluid management in maintenance hemodialysis: a pilot randomized controlled trial. Am J Kidney Dis 2014; 64:111.
  70. Sinha AD, Light RP, Agarwal R. Relative plasma volume monitoring during hemodialysis AIDS the assessment of dry weight. Hypertension 2010; 55:305.
  71. 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 2005; 68:854.
  72. Katzarski KS, Nisell J, Randmaa I, et al. A critical evaluation of ultrasound measurement of inferior vena cava diameter in assessing dry weight in normotensive and hypertensive hemodialysis patients. Am J Kidney Dis 1997; 30:459.
  73. Luik AJ, van Kuijk WH, Spek J, et al. Effects of hypervolemia on interdialytic hemodynamics and blood pressure control in hemodialysis patients. Am J Kidney Dis 1997; 30:466.
  74. Agarwal R, Bouldin JM, Light RP, Garg A. Inferior vena cava diameter and left atrial diameter measure volume but not dry weight. Clin J Am Soc Nephrol 2011; 6:1066.
  75. Joffy S, Rosner MH. Natriuretic peptides in ESRD. Am J Kidney Dis 2005; 46:1.
  76. Agarwal R. B-type natriuretic peptide is not a volume marker among patients on hemodialysis. Nephrol Dial Transplant 2013; 28:3082.
  77. Jaeger JQ, Mehta RL. Assessment of dry weight in hemodialysis: an overview. J Am Soc Nephrol 1999; 10:392.
  78. Kraemer M, Rode C, Wizemann V. Detection limit of methods to assess fluid status changes in dialysis patients. Kidney Int 2006; 69:1609.
  79. K/DOQI Workgroup. K/DOQI clinical practice guidelines for cardiovascular disease in dialysis patients. Am J Kidney Dis 2005; 45:S1.
  80. Jindal K, Chan CT, Deziel C, et al. Hemodialysis clinical practice guidelines for the Canadian Society of Nephrology. J Am Soc Nephrol 2006; 17:S1.
  81. Thomson GE, Waterhouse K, McDonald HP Jr, Friedman EA. Hemodialysis for chronic renal failure. Clinical observations. Arch Intern Med 1967; 120:153.
  82. Raimann J, Liu L, Tyagi S, et al. A fresh look at dry weight. Hemodial Int 2008; 12:395.
  83. Agarwal R, Weir MR. Dry-weight: a concept revisited in an effort to avoid medication-directed approaches for blood pressure control in hemodialysis patients. Clin J Am Soc Nephrol 2010; 5:1255.
  84. Mailloux LU. The overlooked role of salt restriction in dialysis patients. Semin Dial 2000; 13:150.
  85. Ahmad S. Dietary sodium restriction for hypertension in dialysis patients. Semin Dial 2004; 17:284.
  86. Tattersall J, Martin-Malo A, Pedrini L, et al. EBPG guideline on dialysis strategies. Nephrol Dial Transplant 2007; 22 Suppl 2:ii5.
  87. Chazot C, Charra B, Laurent G, et al. Interdialysis blood pressure control by long haemodialysis sessions. Nephrol Dial Transplant 1995; 10:831.
  88. McGregor DO, Buttimore AL, Nicholls MG, Lynn KL. Ambulatory blood pressure monitoring in patients receiving long, slow home haemodialysis. Nephrol Dial Transplant 1999; 14:2676.
  89. Covic A, Goldsmith DJ, Venning MC, Ackrill P. Long-hours home haemodialysis--the best renal replacement therapy method? QJM 1999; 92:251.
  90. Agarwal R. Systolic hypertension in hemodialysis patients. Semin Dial 2003; 16:208.
  91. Santos SF, Peixoto AJ. Revisiting the dialysate sodium prescription as a tool for better blood pressure and interdialytic weight gain management in hemodialysis patients. Clin J Am Soc Nephrol 2008; 3:522.
  92. Thein H, Haloob I, Marshall MR. Associations of a facility level decrease in dialysate sodium concentration with blood pressure and interdialytic weight gain. Nephrol Dial Transplant 2007; 22:2630.
  93. Flanigan MJ, Khairullah QT, Lim VS. Dialysate sodium delivery can alter chronic blood pressure management. Am J Kidney Dis 1997; 29:383.
  94. Krautzig S, Janssen U, Koch KM, et al. Dietary salt restriction and reduction of dialysate sodium to control hypertension in maintenance haemodialysis patients. Nephrol Dial Transplant 1998; 13:552.
  95. Cannella G, Paoletti E, Delfino R, et al. Prolonged therapy with ACE inhibitors induces a regression of left ventricular hypertrophy of dialyzed uremic patients independently from hypotensive effects. Am J Kidney Dis 1997; 30:659.
  96. Tai DJ, Lim TW, James MT, et al. Cardiovascular effects of angiotensin converting enzyme inhibition or angiotensin receptor blockade in hemodialysis: a meta-analysis. Clin J Am Soc Nephrol 2010; 5:623.
  97. Peters CD, Kjaergaard KD, Nielsen CH, et al. Long-term effects of angiotensin II blockade with irbesartan on inflammatory markers in hemodialysis patients: A randomized double blind placebo controlled trial (SAFIR study). Hemodial Int 2017; 21:47.
  98. Zannad F, Kessler M, Lehert P, et al. Prevention of cardiovascular events in end-stage renal disease: results of a randomized trial of fosinopril and implications for future studies. Kidney Int 2006; 70:1318.
  99. Iseki K, Arima H, Kohagura K, et al. Effects of angiotensin receptor blockade (ARB) on mortality and cardiovascular outcomes in patients with long-term haemodialysis: a randomized controlled trial. Nephrol Dial Transplant 2013; 28:1579.
  100. Suzuki H, Kanno Y, Sugahara S, et al. Effect of angiotensin receptor blockers on cardiovascular events in patients undergoing hemodialysis: an open-label randomized controlled trial. Am J Kidney Dis 2008; 52:501.
  101. Takahashi A, Takase H, Toriyama T, et al. Candesartan, an angiotensin II type-1 receptor blocker, reduces cardiovascular events in patients on chronic haemodialysis--a randomized study. Nephrol Dial Transplant 2006; 21:2507.
  102. Hörl MP, Hörl WH. Drug therapy for hypertension in hemodialysis patients. Semin Dial 2004; 17:288.
  103. London GM, Marchais SJ, Guerin AP, et al. Salt and water retention and calcium blockade in uremia. Circulation 1990; 82:105.
  104. Tepel M, Hopfenmueller W, Scholze A, et al. Effect of amlodipine on cardiovascular events in hypertensive haemodialysis patients. Nephrol Dial Transplant 2008; 23:3605.
  105. Hemodialysis Adequacy 2006 Work Group. Clinical practice guidelines for hemodialysis adequacy, update 2006. Am J Kidney Dis 2006; 48 Suppl 1:S2.
  106. Ross EA, Pittman TB, Koo LC. Strategy for the treatment of noncompliant hypertensive hemodialysis patients. Int J Artif Organs 2002; 25:1061.
  107. Matsumoto Y, Mori Y, Kageyama S, et al. Spironolactone reduces cardiovascular and cerebrovascular morbidity and mortality in hemodialysis patients. J Am Coll Cardiol 2014; 63:528.
  108. Lin C, Zhang Q, Zhang H, Lin A. Long-Term Effects of Low-Dose Spironolactone on Chronic Dialysis Patients: A Randomized Placebo-Controlled Study. J Clin Hypertens (Greenwich) 2016; 18:121.
  109. Zazgornik J, Biesenbach G, Janko O, et al. Bilateral nephrectomy: the best, but often overlooked, treatment for refractory hypertension in hemodialysis patients. Am J Hypertens 1998; 11:1364.
  110. Chou KJ, Lee PT, Chen CL, et al. Physiological changes during hemodialysis in patients with intradialysis hypertension. Kidney Int 2006; 69:1833.
  111. Inrig JK, Van Buren P, Kim C, et al. Intradialytic hypertension and its association with endothelial cell dysfunction. Clin J Am Soc Nephrol 2011; 6:2016.
  112. Inrig JK, Patel UD, Toto RD, Szczech LA. Association of blood pressure increases during hemodialysis with 2-year mortality in incident hemodialysis patients: a secondary analysis of the Dialysis Morbidity and Mortality Wave 2 Study. Am J Kidney Dis 2009; 54:881.
  113. Agarwal R, Light RP. Intradialytic hypertension is a marker of volume excess. Nephrol Dial Transplant 2010; 25:3355.
  114. Van Buren PN, Kim C, Toto R, Inrig JK. Intradialytic hypertension and the association with interdialytic ambulatory blood pressure. Clin J Am Soc Nephrol 2011; 6:1684.
  115. Inrig JK, Molina C, D'Silva K, et al. Effect of low versus high dialysate sodium concentration on blood pressure and endothelial-derived vasoregulators during hemodialysis: a randomized crossover study. Am J Kidney Dis 2015; 65:464.