Management of blood pressure in people on dialysis: UKKA clinical practice guideline

Cardiovascular disease is a significant cause of mortality in adults receiving dialysis for end-stage kidney disease, with similar trends being seen in children and young people (CYP). In both populations, the number of people receiving dialysis is increasing.

Hypertension, which affects around 90% of dialysis patients, is a modifiable risk factor for cardiovascular disease in adults and for left-ventricular hypertrophy in CYP. Adults on long-term dialysis are also at increased cardiovascular risk from intradialytic hypotension and declining blood pressure (BP) over time.

Globally, there is no contemporary clinical practice guideline to assist healthcare professionals in the management of BP in dialysis patients. This reflects a lack of good-quality evidence to inform recommendations.

Through a rigorous literature review, grading of evidence and a consensus approach, a group of healthcare professionals with experience in kidney disease has developed a comprehensive guideline to address this critical need. Its aim is to promote a standardised approach to blood pressure management, improve quality of care and reduce disparities in outcomes.

The key recommendations, which are summarised in the guideline under the categories shown below, include:

• Measurement of BP: Intradialytic ambulatory BP monitoring (AMBP) as the gold standard, with home BP monitoring and standardised clinic BP readings for ongoing monitoring.
• BP targets: A pre-dialysis systolic BP range of 140–165 mmHg and post-dialysis systolic BP range of 120–140 mmHg for haemodialysis patients.
• Lifestyle modification: Salt reduction to a maximum intake of 5 g/day and regular exercise.
• Dialysis and dialysate: Extended dialysis hours and modifications can help reduce intradialytic hypotension and improve BP stability.
• Dry weight optimisation: Avoid significant underhydration, and regularly and systematically assess for fluid volume status to guide alterations to dry/target weight and ultrafiltration volume.
• Medication: Beta-blockers as first-line therapy for hypertension in haemodialysis patients, with ACE inhibitors as third-line owing to risk of hypotension.
• CYP: Target BP below the 90^th percentile for age, height and sex, with 24-hour ABPM where feasible.

The strength of the recommendations is influenced by the evidence underpinning them, which is often of moderate to low quality. The report concludes, therefore, with a list of research recommendations, with a view to informing future guidelines.

A review article including the rationale and process for producing the guideline can be read here, while the full report is available here.