Thread by @ISNeducation

How many of your dialysis patients have well controlled blood pressure?📋

Admit it! Hypertension in dialysis patients is a universal problem!☹️
The next edition of Nuances in Nephrology will address this and more!
Register now! 🔗register.gotowebinar.com/register/21253…
But to give you a head start, here’s a #ISNtweetorial
#meded #tweetorials

❗Data suggests that approximately 50-60% of hemodialysis (HD) patients are hypertensive

‼️In a study of 2535 adult HD pts, 86% were found to be hypertensive🤯

pubmed.ncbi.nlm.nih.gov/12967694/

Even among peritoneal dialysis patients, >80% have hypertension 😳
pubmed.ncbi.nlm.nih.gov/10383021/

Possible causes of hypertension (HTN) in HD patients include 👇
🚩 Volume overload (most common) 🌊
🚩 ⬆️ Symp drive
🚩 RAAS activation
🚩 Arteriosclerosis
🚩 ⬆️ Endothelins
🚩 ⬆️ Intracellular Ca2+
kidney-international.org/article/S0085-…

Less common causes of HTN in HD:
🚩⬇️Renalase (catecholamine metabolising enzyme released by kidney)
🚩 Use of
◾erythropoietin stimulating agents💉
◾️nasal decongestants 🤧
◾️NSAIDs💊
◾️illicit drugs 🧪 and
◾️herbal remedies 🌿

Figure 3 from pubmed.ncbi.nlm.nih.gov/24137013/

So why is HTN in dialysis so bad? 🤔
🛑'U shaped' curve between pre and post HD BP and mortality
🛑Associated with adverse cardiovascular outcome 💔

Figures 2 and 3 from nature.com/articles/s4159…

👉Diagnosis of HTN in dialysis patients:

📌 Pre- and post dialysis BP measurements

✅ Convenient (and so most commonly used)
❌ Poor correlation with ABPM
❌ Pre HD BP tends to overestimate and post HD BP tends to underestimate actual BP

Figure 1 from pubmed.ncbi.nlm.nih.gov/28340239/

📌 Home 🏘️ BP monitoring
✅ Easy to check
✅ Good correlation with ABPM
✅ Higher short-term reproducibility
❌ Absence of information on nocturnal dipping

📌 Gold 🏅standard ➡️
Ambulatory Blood Pressure Monitoring (ABPM)
⚙️ Shows linear ⬆️ with ⬆️ volume
✅ Accurate
✅ Good correlation with outcome
❌ Cumbersome
❌ Inconvenient
kidney-international.org/article/S0085-…

👉BP target for HD patients:
⚠️Differs according to the method used
KDOQI-2004 ➡️ kidneyfoundation.cachefly.net/professionals/…

ESH-ESC 2017 ➡️ pubmed.ncbi.nlm.nih.gov/28340239/

👉Target BP for PD patients ➡️

Home BP <135/85 mmHg over 7 consecutive days
Office BP <140/90 mmHg
24 hour ABPM <130/80 mmHg

👉 Non pharmacological intervention to control BP in HD patients:
✅ Achieve optimal dry weight
◾ Properly assess volume status 💧
◾⬆️ HD time ⌚
◾⬇️ Dialysate Na 💈
◾⬇️ Dietary Na intake 🥗
✅ Probe for drug induced HTN 💊
nature.com/articles/nrnep…

👉 Pharmacological intervention for BP control in dialysis patients:
From the 2004 NKF/KDOQI guidelines ➡️

Is your dialysis patient having persistent HTN in spite of being on several antihypertensive drugs ❓❓
✅ Make sure the drugs are not dialyzable
✅ Rule out other possible causes of ⬆️BP

cjasn.asnjournals.org/content/11/11/…

For PD patients also, volume overload is an important factor and may occur due to various reasons
cjasn.asnjournals.org/content/14/2/2…

Think you have a rough idea about HTN in dialysis now? Take this quiz and test your knowledge 👇theisn.outgrow.us/Copy-of-theisn…

We are the #ISNtweetorial team. Our aim is to have a new 🧵 up along with the nuances in Nephrology webinar. Do give us a follow! @arvindcanchi @gag_aggarwal @sibgokcay @xaviervel @elliotktannor @FerArceAmare @NamrataYParikh