UK Kidney Association Clinical Practice Guideline: Management of Blood Pressure in Adults, Children and Young People on Dialysis
Lead Author: Prof Indranil Dasgupta
Consultant Nephrologist, University Hospitals Birmingham NHS Foundation Trust & School of Health Sciences, University of Birmingham
- Final Version: January 2025
- Review Date: January 2028
The Guideline
The UK adult population receiving dialysis continues to increase. Between 2020-2021, the annual increase was 1.5%, compared with 2-2.5% seen prior to the COVID-19 pandemic. The average age of adults receiving dialysis is older (66.1 years for HD and 63.3 years for PD) with a longer duration of therapy required (median duration 3.2 years) when compared with published registry data from 2010 (1, 2).
- Proportion of adult dialysis patients having ABPM for diagnosis of de novo hypertension.
- Proportion of adult dialysis patients using HBPM or standardized out-of-dialysis unit BP measurements to monitor treatment of hypertension.
- Proportion of adult dialysis patients who have received advice and support to reduce salt intake to <5 g/day.
- Proportion of haemodialysis sessions where patients (adults and CYP) experience symptomatic IDH as defined by The UK Kidney Association (164, 190).
- Proportion of patients (adults and CYP) who have routine (e.g. minimum 3 monthly) assessment of dry weight.
- Proportion of hypertensive adult haemodialysis patients prescribed β-blockers.
- Proportion of hypertensive adult peritoneal dialysis patients prescribed ACEis or ARBs
- Proportion of CYP on dialysis undergoing annual ABPM assessment.
- Proportion of hypertensive CYP with LVH.
- Proportion of CYP on dialysis on antihypertensive medications and, in those taking antihypertensives, the number of agents used.
- Pragmatic RCT comparing management of hypertension using routine (including ‘usual’ dialysis unit BP in in-centre haemodialysis patients) BP, HBPM and ABPM in dialysis patients.
- Pragmatic RCT in both haemodialysis and peritoneal dialysis to determine optimal BP target ranges, preferably utilising standardised office BP or home BP monitoring as the primary method for measuring BP
- RCT of multiple lifestyle interventions (including dietary salt and fluid reduction, exercise and psychosocial support for medication adherence) on BP and symptomatic IDH in people on dialysis.
- An implementation or hybrid effectiveness-implementation study of protocolised fluid volume management to improve CV outcomes in people receiving haemodialysis.
- RCT to determine whether routine evening/night-time dosing of antihypertensive medication reduces incidence of symptomatic intra-dialytic hypotension.
- RCT to determine effectiveness of midodrine and/or L-carnitine in preventing symptomatic IDH and reducing hospitalisations, and whether these treatments are well tolerated and safe.
- RCT in CYP on dialysis to determine whether those in whom BP is targeted to <90th centile have a lower risk of LVH compared with those in whom BP is permitted ≥90th centile.
- Study in CYP on dialysis to determine whether HBPM values correlate with data from ABPM assessment.
High blood pressure (BP) is very common in people with end stage kidney disease (ESKD) on dialysis. It is a risk factor for heart disease, which is the most common cause of death in people on dialysis. Managing high BP in people on dialysis is not always straightforward because of a lack of good quality research evidence on how and when to measure BP, what target BP to aim for, and how to best use different strategies to control BP with diet, exercise, dialysis techniques and medications.
Topic group membership
BP Measurement: Mariyam Adam, Indranil Dasgupta
Blood pressure targets: Indranil Dasgupta, Douglas Stewart, Kieran McCafferty, Tim Doulton
Lifestyle modification: Katie Durman, Pauline Swift
Dry weight: Kieran McCafferty, Manish Sinha, Indranil Dasgupta, Ed Jenkinson
Dialysis and dialysate: Anna Forbes, Pauline Swift, Stan Fan
Medication: Tim Doulton, Charlotte Mallindine
Children & young people: Manish Sinha, Douglas Stewart
Lay representative: Ed Jenkinson
PICOS for literature search, search strategies & PRISMA flowchart
PICOS
Eligibility Criteria:
Population: Adults, children and young people receiving dialysis (haemodialysis, haemodiafiltration and peritoneal dialysis) for end stage renal disease
Intervention:
- Any intervention intended to reduce blood pressure (BP), to include but not limited to: blood pressure lowering medication; target/dry weight reduction or optimization; dialysis prescription, including ultrafiltration volumes, ultrafiltration rate; diet, including salt restriction; exercise or other lifestyle intervention; self-management techniques.
- Any intervention intended to mitigate intradialytic hypotension (IDH) or other hypotensive episodes, including low temperature dialysis, ultrafiltration profiling, dialysate sodium concentration and profiling, midodrine use.
Dialysability of blood pressure lowering medication
Beta Blockers
| Medication | Dialysed in HDF/High Flux | Dialysed in PD | Half life (hrs) | Half life in ESRF (hrs) |
|---|---|---|---|---|
| Atenolol | Dialysed | Not dialysed | 6–7 | 15–35 |
| Bisoprolol | Dialysed | Not dialysed | 9–12 | 18–24 |
| Carvedilol | Not dialysed | Unlikely | 6–10 | Unchanged |
| Labetalol | Unknown | Not dialysed | 4–8 | Unchanged |
| Metoprolol | Dialysed | Not dialysed | 1–9 | Unchanged |
| Propranolol | Unknown | Not dialysed | 2–6 | Unchanged |
References
Ashby D, Borman N, Burton J, Corbett R, Davenport A, Farrington K, et al. Renal Association Clinical Practice Guideline on Haemodialysis. BMC Nephrol. 2019;20(1):379.
Registry UR. UK Renal Registry 25th Annual Report – data to 31/12/2021, Bristol, UK2023. Available from: https://ukkidney.org/audit-research/annual-report.
Mitsnefes MM. Cardiovascular disease in children with chronic kidney disease. J Am Soc Nephrol. 2012;23(4):578-85.
Agarwal R. Blood pressure and mortality among hemodialysis patients. Hypertension. 2010;55(3):762-8.
Bansal N, McCulloch CE, Lin F, Alper A, Anderson AH, Cuevas M, et al. Blood Pressure and Risk of Cardiovascular Events in Patients on Chronic Hemodialysis: The CRIC Study (Chronic Renal Insufficiency Cohort). Hypertension. 2017;70(2):435-43.
Fusce venenatis aliquam?
Lorem ipsum dolor sit amet, consectetur adipiscing elit, sed do eiusmod tempor incididunt ut labore et dolore magna aliqua.