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Hypertension in dialysis patients: a consensus document by the European Renal and Cardiovascular Medicine (EURECA-m) working group of the European Renal Association – European Dialysis and Transplant Association (ERA-EDTA) and the Hypertension and the Kidney working group of the European Society of Hypertension (ESH)*

Sarafidis, Pantelis A.; Persu, Alexandre; Agarwal, Rajiv; Burnier, Michel; de Leeuw, Peter; Ferro, Charles; Halimi, Jean-Michel; Heine, Gunnar; Jadoul, Michel; Jarraya, Faical; Kanbay, Mehmet; Mallamaci, Francesca; Mark, Patrick B.; Ortiz, Alberto; Parati, Gianfranco; Pontremoli, Roberto; Rossignol, Patrick; Ruilope, Luis; Van der Niepen, Patricia; Vanholder, Raymond; Verhaar, Marianne C.; Wiecek, Andrzej; Wuerzner, Gregoire; London, Gérard M.; Zoccali, Carmine

doi: 10.1097/HJH.0000000000001283

In patients with end-stage renal disease treated with hemodialysis or peritoneal dialysis, hypertension is very common and often poorly controlled. Blood pressure (BP) recordings obtained before or after hemodialysis display a J-shaped or U-shaped association with cardiovascular events and survival, but this most likely reflects the low accuracy of these measurements and the peculiar hemodynamic setting related with dialysis treatment. Elevated BP by home or ambulatory BP monitoring is clearly associated with shorter survival. Sodium and volume excess is the prominent mechanism of hypertension in dialysis patients, but other pathways, such as arterial stiffness, activation of the renin–angiotensin–aldosterone and sympathetic nervous systems, endothelial dysfunction, sleep apnea and the use of erythropoietin-stimulating agents may also be involved. Nonpharmacologic interventions targeting sodium and volume excess are fundamental for hypertension control in this population. If BP remains elevated after appropriate treatment of sodium-volume excess, the use of antihypertensive agents is necessary. Drug treatment in the dialysis population should take into consideration the patient's comorbidities and specific characteristics of each agent, such as dialysability. This document is an overview of the diagnosis, epidemiology, pathogenesis and treatment of hypertension in patients on dialysis, aiming to offer the renal physician practical recommendations based on current knowledge and expert opinion and to highlight areas for future research.

aDepartment of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece

bPole of Cardiovascular Research, Institut de Recherche Expérimentale et Clinique

cDivision of Cardiology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium

dDepartment of Medicine, Indiana University School of Medicine

eRichard L. Roudebush Veterans Administration Medical Center, Indianapolis, Indiana, USA

fService of Nephrology and Hypertension, Lausanne University Hospital, Lausanne, Switzerland

gDepartment of Medicine, Maastricht University Medical Center, Maastricht

hZuyderland Medical Center, Geleen, The Netherlands

iDepartment of Renal Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK

jService de Néphrologie-Immunologie Clinique, Hôpital Bretonneau, François-Rabelais University, Tours, France

kSaarland University Medical Center; Internal Medicine IV - Nephrology and Hypertension, Homburg, Germany

lDivision of Nephrology, Cliniques universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium

mDepartment of Nephrology, Sfax University Hospital

nResearch Unit, Faculty of Medicine, Sfax University, Sfax, Tunisia

oDivision of Nephrology, Department of Medicine, Koc University School of Medicine, Istanbul, Turkey

pCNR-IFC, Clinical Epidemiology and Pathophysiology of Hypertension and Renal Diseases Unit, Ospedali Riuniti, Reggio Calabria, Italy

qInstitute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK

rIIS-Fundacion Jimenez Diaz, School of Medicine, University Autonoma of Madrid, FRIAT and REDINREN, Madrid, Spain

sDepartment of Cardiovascular, Neural, and Metabolic Sciences, San Luca Hospital, Istituto Auxologico Italiano

tDepartment of Medicine and Surgery, University of Milano-Bicocca, Milan

uUniversità degli Studi and IRCCS Azienda Ospedaliera Universitaria San Martino IST, Genova, Italy

vINSERM, Centre d’Investigations Cliniques Plurithématique 1433, UMR 1116, Université de Lorraine, CHRU de Nancy

wF-CRIN INI-CRCT Cardiovascular and Renal Clinical Trialists, Nancy, France

xHypertension Unit & Institute of Research i+12, Hospital Universitario 12 de Octubre, Madrid, Spain

yDepartment of Nephrology and Hypertension, Universitair Ziekenhuis Brussel - VUB, Brussels

zNephrology Section, Department of Internal Medicine, Ghent University Hospital, Gent, Belgium

aaDepartment of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, The Netherlands

bbDepartment of Nephrology, Transplantation and Internal Medicine Medical University of Silesia in Katowice, Katowice, Poland

ccManhes Hospital and FCRIN INI-CRCTC, Manhes, France

Correspondence to Pantelis A. Sarafidis, MD, MSc, PhD, Department of Nephrology, Hippokration Hospital, Aristotle University Thessaloniki, Konstantinoupoleos 49, GR54642 Thessaloniki, Greece. Tel: +30 2310 992796; fax: +30 2310 688969; e-mail:

Abbreviations: ABPM, ambulatory blood pressure monitoring; ACEI, angiotensin-converting enzyme inhibitor; ADMA, asymmetric dimethylarginine; AIx, augmentation index; ALCHEMIST, ALdosterone Antagonist Chronic HEModialysis Interventional Survival Trial; ARB, angiotensin-II receptor blocker; BLOCADE, beta-blocker to LOwer CArdiovascular Dialysis Events study; BP, blood pressure; CAPD, continuous ambulatory peritoneal dialysis; CCB, calcium channel blocker; CI, confidence interval; CKD, chronic kidney disease; CRIC, Chronic Renal Insufficiency Cohort study; DOHAS, Dialysis Outcomes Heart Failure Aldactone Study; DOPPS, Dialysis Outcomes and Practice Patterns Study; DRIP, Dry-Weight Reduction in Hemodialysis Patients study; eGFR, estimated glomerular filtration rate; eNOS, endothelial nitric oxide synthase; ERA-EDTA, European Renal Association – European Dialysis and Transplant Association; ESAs, erythropoietin-stimulating agents; ESH, European Society of Hypertension; ESRD, end-stage renal disease; EURECA-m, European Renal and Cardiovascular Medicine Working Group; FOSIDIAL, Fosinopril in Dialysis study; HDPAL, Hypertension in Hemodialysis Patients Treated with Atenolol or Lisinopril study; HR, hazard ratio; KEEP, Kidney Early Evaluation Program; LUST, Lung Water by Ultra-Sound Guided Treatment to Prevent Death and Cardiovascular Complications in High Risk ESRD Patients with Cardiomyopathy study; LV, left ventricular; LVH, left ventricular hypertrophy; MRA, mineralocorticoid receptor antagonist; NKF-KDOQI, National Kidney Foundation – Kidney Disease Outcomes Quality Initiative; NO, nitric oxide; OCTOPUS, Olmesartan Clinical Trial in Okinawa Patients under Dialysis study; PP, pulse pressure; PRA, plasma renin activity; PWV, pulse wave velocity; RAAS, renin–angiotensin–aldosterone system; rhuEPO, recombinant erythropoietin; RR, relative risk; TonEBP, tonicity-responsive enhancer-binding protein; VEGF, vascular endothelial growth factor

Received 13 November, 2016

Accepted 10 January, 2017

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