Blood Pressure Control in Peritoneal Dialysis Patients.
Contrib Nephrol. 2018;196:148-154
Authors: Ryuzaki M
In the general population, hypertension (HT) is defined as systolic blood pressure (SBP) ≥140 mm Hg and/or diastolic blood pressure (DBP) ≥90 mm Hg. In dialysis patients, the definition is thought to be the same as in the general population. But there is no clear description about the definition of HT for dialysis patients, especially in peritoneal dialysis (PD) patients. The prevalence of HT in PD patients is much higher compared to the general population. The association of BP and cardiovascular (CV) mortality in PD patients who are not exposed to huge hemodynamic changes during hemodialysis (HD) has been inconsistently reported. The International Society of Peritoneal Dialysis (ISPD) guideline recommends that BP be evaluated by home BP measurement at least once a week and at each visit to the clinic and that active screening and periodic monitoring of BP be performed in this population. When collecting BP data via our telemedicine system, HD patients' weekly BP variability was unclear if data were analyzed by the day of the week, but was clear if data were analyzed by the day of dialysis. There is weekly BP variability probably due to volume status, not due to the day of the week. The range of variability of morning SBP in a week was almost 16 mm Hg in HD patients. But continuous ambulatory PD patients' home morning SBP variability in a week was only 3 mm Hg. Comparing data of PD patients and HD patients, weekly BP variability is much wider in HD, which might increase CV event risk. PD patients should undertake physical activity and salt restriction compatible with CV health and tolerance, which might reduce BP as some reports suggested. Keeping good volume status is crucial for the treatment of BP. Using the bioelectrical impedance device is a good method to measure dry weight. Conventionally, we should check dry weight confirming no edema on body, normal BP and normal heart rate, cardiothoracic ratio, plasma concentration of human atrial natriuretic peptide, diameter of inferior vena cava, etc. Before starting or increasing antihypertensive medications, PD patients with HT should have volume status optimized. Although the utility of hypertonic glucose PD solutions for volume removal in PD is not disputed, the minimization of PD glucose exposure by salt restriction, diuretic use among those with residual renal function, and use of glucose-sparing solutions like icodextrin to optimize volume control are important. PD patients whose BP is consistently >140/90 mm Hg should be treated to maintain SBP at <140 mm Hg and DBP at <90 mm Hg. There are no randomized studies examining different BP targets in relation to clinical outcomes in PD patients. As a perspective, evidence for BP control in PD patients is awaited.
PMID: 30041220 [PubMed - in process]