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Intensive hemodialysis improves blood pressure control and reduces need for antihypertensive agents

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Persistent hypertension is a vexing problem in the care of dialysis patients.1 Perennially, blood pressures over 140/90 are the second leading cause of kidney failure in the U.S..2 Antihypertensive medications are widely used and polypharmacy is common, but pharmacologic intervention is often unsuccessful at lowering blood pressure to normotensive levels.3

Trials have shown intensive hemodialysis reduces blood pressure

  • In the Daily Trial of the Frequent Hemodialysis Network, intensive hemodialysis reduced pre-dialysis systolic blood pressure (SBP) by 7.7 mmHg, relative to three sessions per week.4
  • In the Nocturnal Trial of the Frequent Hemodialysis Network, intensive hemodialysis reduced pre-dialysis SBP by 7.3 mmHg, relative to three sessions per week, a finding also reported in an earlier Canadian trial.4,5

Trials and prospective cohort studies alike have shown that intensive hemodialysis reduces the need for antihypertensive medications

  • Both intensive schedules in the Frequent Hemodialysis Network reduced antihypertensive medication use, relative to three sessions per week.4
  • In the Following Rehabilitation, Economics, and Everyday Dialysis Outcomes Measurements (FREEDOM) Study of short daily hemodialysis, the mean number of prescribed antihypertensive agents decreased from 1.7 to 1.0 in one year, while the percentage of patients not prescribed antihypertensive agents increased from 21% to 47%.6

Conclusion

Multiple randomized and prospective cohort studies demonstrate that intensive hemodialysis significantly lowers pre-dialysis blood pressure and reduces the need for antihypertensive medications. By lowering blood pressure, intensive hemodialysis may improve cardiovascular outcomes.

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All forms of hemodialysis, including treatments performed in-center and at home, involve some risks. In addition, there are certain risks unique to treatment in the home environment. Patients differ and not everyone will experience the reported benefits of more frequent hemodialysis.

Certain risks associated with hemodialysis treatment are increased when performing solo home hemodialysis because no one is present to help the patient respond to health emergencies.

Certain risks associated with hemodialysis treatment are increased when performing nocturnal therapy due to the length of treatment time and because therapy is performed while the patient and care partner are sleeping.

References

  1. Rao MV, Qiu Y, Wang C, Bakris G. Hypertension and CKD: Kidney Early Evaluation Program (KEEP) and National Health and Nutrition Examination Survey (NHANES), 1999-2004. Am J Kidney Dis. 2008;51(4 Suppl 2):S30-S37. doi:10.1053/j.ajkd.2007.12.012.
  2. Saran R, Li Y, Robinson B, et al. US Renal Data System 2014 Annual Data Report: Epidemiology of Kidney Disease in the United States. Am J Kidney Dis. 2015;66(1 Suppl 1):Svii, S1-S305. doi:10.1053/j.ajkd.2015.05.001.
  3. Bakris GL, JM Burkhart, Weinhandl ED, McCullough PA, Kraus MA. Intensive Hemodialysis, Blood Pressure, and Antihypertensive Medication Use. Am J Kidney Dis. 2016;68(5)(suppl 1):S15-S23.
  4. Kotanko P, Garg AX, Depner T, et al. Effects of frequent hemodialysis on blood pressure: Results from the randomized frequent hemodialysis network trials. Hemodial Int. 2015;19(3):386-401. doi:10.1111/hdi.12255.
  5. Culleton BF, Walsh M, Klarenbach SW, et al. Effect of frequent nocturnal hemodialysis vs conventional hemodialysis on left ventricular mass and quality of life: a randomized controlled trial. JAMA. 2007;298(11):1291-1299. doi:10.1001/jama.298.11.1291.
  6. Jaber BL, Collins AJ, Finkelstein FO, et al. Daily hemodialysis reduces the need for anti-hypertensive medications. October 2009. https://www.asn-online.org/api/download/?file=/education/kidneyweek/archives/RW09Abstracts.pdf. Accessed May 20, 2015.
  7. The DOPPS Practice Monitor. http://www.dopps.org/DPM/. Accessed May 20, 2015.