Hypertension in Hemodialysis. An Overview on Physiopathology and Therapeutic Approach in Adults and Children

Chronic Kidney disease (CKD) patients, particularly those with end stage renal disease (ESRD), are at much higher risk of cardiovascular disease than the general population. Cardiovascular disease is by far the leading cause of morbidity and mortality in dyalisis patients, accounting for almost 40% of hospitalizations and almost 50% of deaths. Hypertension is the single most important factor for the development of cardio and cerebrovascular complications. The etio-pathogenesis of hypertension in dialysis patients is multifactorial, sodium excess and extracellular volume expansion is the major factor in the development of hypertension, however there are other pathogenetic factors that should be considered, such as renin-angiotensin system hyperactivity, increased sympatic activity, altered endothelial cell function, hyperparathiroidism, and oxidative stress. The most important risk factors are anemia, hypoalbuminemia, chronic inflammation, prothrombotic factors, hyperomocisteinemia, vascular calcification and the traditional factors for cardiovascular risk (age, male gender, diabetes mellitus, dyslipidemia, smoke, physical inactivity, alcohol abuse). Elevated blood pressure is frequent also in children on long term dialysis therapy. Data suggest that uremic factors or factors related to renal replacement therapy may be implicated in the pathogenesis of heart disease in adults and pediatric patients, because cardiovascular survival improves after transplantation. The management of hypertension requires lifestyle modifications and control of volume status, with dietary salt and fluid restriction in combination with reduction of dialysate sodium concentration or with programmed “variable–sodium” dialy-