Treatment-resistant hypertension in the hemodialysis population: a 44-h ambulatory blood pressure monitoring-based study

Abstract

Background: Uncontrolled hypertension notwithstanding the use of at least three drugs or hypertension controlled with at least four drugs, the widely accepted definition of treatment-resistant hypertension (TRH), is considered as a common problem in the hemodialysis population. However, to date there is no estimate of the prevalence of this condition in hemodialysis patients. Method: We estimated the prevalence of TRH by 44-h ambulatory BP monitoring (ABPM) in 506 hemodialysis patients in 10 renal units in Europe included in the registry of the European Renal and Cardiovascular Medicine (EURECAm,), a working group of the European Association, European Dialysis and Transplantation Association (ERA EDTA). In a sub-group of 114 patients, we tested the relationship between fluid overload (Body Composition monitor) and TRH. Results: The prevalence of hypertension with 44-h ABPM criteria was estimated at 85.6% (434 out of 506 patients). Of these, 296 (58%) patients were classified as uncontrolled hypertensive patients by 44-h ABPM criteria (≥130/80 mmHg). Two hundred and thirteen patients had uncontrolled hypertension while on treatment with less than three drugs and 210 patients were normotensive while on drug therapy (n = 138) or off drug treatment (n = 72). The prevalence of TRH was 24% (93 among 386 treated hypertensive patients). The prevalence of predialysis fluid overload was 33% among TRH patients, 34% in uncontrolled hypertensive patients and 26% in normotensive patients. The vast majority (67%) of hemodialysis patients with TRH had no fluid overload. Conclusion: TRH occurs in about one in four treated hypertensive patients on hemodialysis. Fluid overload per se only in part explains TRH and the 67% of these patients show no fluid overload.

Current apparent treatment‐resistant hypertension in patients undergoing peritoneal dialysis: A multi‐center cross‐sectional study

“… 14 , 32 , 33 Thus, HD patients have a similar aTRH prevalence of 18%–24% to the predialysis CKD patients. 1 , 11 , 14 Our data in HD patients reconfirmed the aTRH prevalence of 16.9% (data were not shown). In patients undergoing PD, the sodium and water retention becomes a prominent problem due to inefficient peritoneal transportation, especially in those with peritonitis and micro‐inflammation, long term glucose exposure, and peritoneal fibrosis.…”

“…In some studies, younger patients were related to higher aTRH prevalence 14 . To date, association of aTRH has not mentioned in ESRD patients undergoing dialysis 1,14 . In our population, younger and higher BMI were associated with higher aTRH incident.…”

“… 18 , 19 In the study from HD patients, diuretics was not considered as one anti‐hypertensive class. 1 In our study, 36.1% PD patients were anuria, the average 24‐h urine volume was 0.3 (0–0.7) liters, and only 22.7% PD patients have received diuretics. When considered diuretics as one anti‐hypertensive class, the prevalence of aTRH was 50.4% (data were not shown).…”

“…Hypertension is a most common complication in end staged renal disease (ESRD) patients undergoing dialysis with the prevalence about 90%, and is notoriously difficult to control. 1 , 2 , 3 , 4 Resistant hypertension (RH), also called difficult‐to‐treat hypertension, is generally defined as failure to control blood pressure (BP) concurrently using at least three anti‐hypertensive drugs, or hypertension controlled by at least four medications. 5 This definition represents a heterogeneous patient group, including those with uncontrolled or controlled BP, pseudo‐resistance (e.g., white‐coat hypertension, inaccurate BP measurements, or elevated BP because of non‐adherence to drugs), and refractory hypertension (RfH) (uncontrolled BP with at least five anti‐hypertensive medication classes).…”

“… 8 , 12 , 13 In two studies from hemodialysis (HD) patients, the prevalence seemed to be similar (18%–24%) compared to those on predialysis CKD population. 1 , 14 Nevertheless, research focused on peritoneal dialysis (PD) population is lacking.…”