1. Dr.M.shafiee Department of internal medicine Shiraz university of medical sciences

4.  mean home BP>135/85  mean ABPM>130/80  Mean interdialytic BP at mead week >140/90

5.  Dialysis Unit: During, Before, or After  Home BP  ABPM

6.  Predialysis SBP overestimated mean SBP by an average of 10 mm Hg  Postdialysis SBP underestimated mean SBP by an average of 7 mm Hg  BP readings over a period of 1 to 2 weeks rather than isolated readings should be used

8.  Sodium and volume overload.  Sympathetic nervous system activity  Inappropriate renin secretion.  Alteration in endothelin and nitric oxide.  Erythropoietin therapy.  Hyperparathyroidism.  Others: Uremic toxins, Nocturnal hypoxemia and sleep disturbances  Essential Hypertension before ESRD

9.  Hypervolemia is the major factor  Positive Sodium balance  Increases intake and decreased excretion  Achieving DW will control 60% of cases of HTN

10. Management

11.  Step 1: Lifestyle modifications and control of volume status with lifestyle modifications.  Step 2: Control of volume status with dialysis.  Step 3: Administration of antihypertensive drugs

12.  Restriction of Na and water and fluid  Restriction of salt to maximum 5gr per day  Exercise

13.  Control of volume status  Limit interdialytic weight gain  a 2.5 kg is associated with a significant increase in BP  Achieve dry weight  Frequent dialysis & Longer dialysis time

14.  Criteria to determining DW:  No marked fall in BP during dialysis.  No hypertension (predialysis BP at the beginning of the week <140/90 mm Hg).  No peripheral edema.  No pulmonary congestion on chest X-ray.  Cardiothoracic ratio ≤50% (≤53% in females).

15.  Na restriction and dry weight can control BP in 80- 90% of patients  The absence of edema dose not exclude the hypervolemia

16.  Antihypertensive drugs are indicated in patients in whom hypertension persist, despite seemingly adequate volume control  All classes of antihypertensive drugs can be used in dialysis patients, with the sole exception of diuretics  The selection of antihypertensive agents is frequently dictated by the presence of comorbid conditions

17.  ARBs and ACE are the preferable first line of antihypertensive drugs  They are well tolerated and are particularly effective in patients with a history of heart failure due to systolic dysfunction and may induce a more rapid regression of LVH  They may aggravate anemia by reducing the action of erythropoietin

18.  They are indicated in patients who have had a recent MI or suffer from angina pectoris  Potential side effects include CNS depression Bradycardia, altered lipid profiles,hyperkalemia altered response to hypoglycemia and bronchospasm

19.  They are effective and well tolerated in dialysis patients  In this group Amlodipin can decrease mortality

20.  Methyl doppa and clonidine are in this group  But due to infavorable side effects use of them are limitted

21.  Blood pressure remaining above goal in spite of concurrent use of 3 antihypertensive agents of different classes

22.  The use of non steroidal anti-inflammatory drugs  Renovascular hypertension  Increasing cysts in polysystic kidney disease  Compliance

23.  If a treatable cause cannot be found,minoxidil in combination with beta blocker may be effective  Spironolactone in Hemodialysis Patients 25-50 mg post dialysis  Risk of hyperkalemia  Improve EF and Improve BP control  Large studies are done

24.  Renal sympathetic nerve ablation  Bilateral nephrectomy May be considered in the rare, noncompliant individual with life-threatening hypertension unable to be controlled with any dialysis modality

25.  5-15%  Mechanism  Endothelial dysfunction  Activation of renin angiotensin system  Sodium level  Activation of systematic nervous system  Extracellular volume overload

26.  The most important treatment is adequate sodium and water removal and reducing sympathetic hyperactivity.  Changing to non-dialyzable antihypertensive medications  Altering the dialysis prescription

27.  ACEI or αblocker at the time of hypertension or befor hemodialysis  Carvedilol, which blocks endothelin-1 release, appears to be effective in this setting

28. Thank you