Top Things to Know: HTN in Patients Treated with In-Center Maintenance Hemodialysis: Current Evidence and Future Opportunities

Published: April 24, 2023

  1. Nearly 500,000 individuals are treated with maintenance hemodialysis for kidney failure in the U.S. and roughly half will die from cardiovascular causes.
  2. Hypertension, an important and modifiable risk factor for cardiovascular disease, is observed in over 80% of patients treated with maintenance hemodialysis.
  3. To date, no large-scale randomized clinical trials have specifically addressed blood pressure (BP) targets in patients treated with maintenance hemodialysis and thus there are no widely accepted blood pressure targets to treat to in this population.
  4. This scientific statement reviews current evidence on defining, diagnosing and treating hypertension in patients treated with maintenance hemodialysis and highlight opportunities for future investigation, including studies on blood pressure targets and treatment strategies.
  5. The pathogenesis of hypertension in patients treated with maintenance hemodialysis is complex and rests on the interplay of extracellular hypervolemia, overactivity of the sympathetic and renin-angiotensin-aldosterone systems, pathologic vascular changes, and other hormonal and clinical conditions.
  6. The pathophysiology of hypertension in patients treated with maintenance hemodialysis is multifactorial and differs from that seen in other patient populations.
  7. Home blood pressure monitoring (HBPM) is a reasonable alternative to obtain interdialytic measurement and has shown to closely correlate with 44- hour ambulatory blood pressure. 44-hour interdialytic ambulatory blood pressure has been a superior risk predictor for mortality in patients treated with maintenance hemodialysis and can account for volume-related increases in blood pressure during the interdialytic period.
  8. Factors that contribute to hypertension in patients treated with hemodialysis include volume overload, arterial stiffness, enhanced activity of the sympathetic nervous and renin angiotensin-aldosterone systems, endothelial dysfunction, and use of erythropoietin-stimulating agents.
  9. Measuring blood pressure accurately in a patient on hemodialysis can be challenging. Some obstacles are in-patient dialysis centers are not quiet and proper position for measurement may not be possible, many patients treated with maintenance hemodialysis have bilateral upper arm vascular access sites and patients may have vascular abnormalities (arterial stiffness and occlusive peripheral arterial disease) which can significantly affect a measured blood pressure.
  10. The statement provides a table summarizing the dialyzability of common antihypertensive drugs. The following four factors determine dialyzability of drugs and include: 1) magnitude of protein binding; 2) volume of distribution; 3) molecular weight; 4) interactions with the dialyzer/hemofilter membrane.


Bansal N, Artinian NT, Bakris G, Chang T, Cohen J, Flythe J, Lea J, Vongpatanasin W, Chertow GM; on behalf of the American Heart Association Council on the Kidney in Cardiovascular Disease; Council on Cardiovascular and Stroke Nursing; and Council on Epidemiology and Prevention. Hypertension in patients treated with in-centermaintenance hemodialysis: current evidence and future opportunities: a scientific statement from the AmericanHeart Association [published online ahead of print April 24, 2023]. Hypertension. doi: 10.1161/HYP.0000000000000230