This Article Abstract Free Full Text (Free PDF) Free Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Saved Citations Download to citation manager Request Permissions Request Reprints Add to My Marked Citations Citing Articles Citing Articles via Google Scholar Citing Articles via Scopus Google Scholar Articles by Doulton, T. W. Articles by MacGregor, G. A Search for Related Content PubMed PubMed Citation Articles by Doulton, T. W. Articles by MacGregor, G. A Pubmed/NCBI databases Substance via MeSH Medline Plus Health Information Dialysis Dietary Sodium Kidney Failure Social Bookmarking                         What's this?

Review: Blood pressure in haemodialysis patients: The importance of the relationship between the renin-angiotensin-aldosterone system, salt intake and extracellular volume

Blood Pressure Unit, St George's Hospital Medical School, London, SW17 0RE, UK

Graham A MacGregor

Blood Pressure Unit, St George's Hospital Medical School, London, SW17 0RE, UK, g.macgregor@ sghms.ac.uk

This review outlines the major mechanisms for control of blood pressure (BP) in individuals with renal failure on haemodialysis. Dietary salt stimulates thirst and, thereby, greater fluid intake with excessive fluid gain between dialysis sessions and chronic expansion of extracellular volume. At the same time, this volume expansion often fails to suppress the renin-angiotensin system (RAS) appropriately and this inevitably leads to high BP in the majority of individuals on haemodialysis.

A greater understanding of the mechanisms involved leads to more rational treatment and better BP control. This can be achieved by careful measurement of BP before and after dialysis, allowing time for the equilibration of extracellular fluid shifts that occur after dialysis, combined with measurements of plasma renin activity. It is relatively easy to then decide how the high BP should be treated either by removal of excess volume by gradual ultrafiltration combined with restriction of salt intake to help prevent thirst and excessive fluid gain between dialyses, or by inhibition of the RAS, or by a combination of both.

In those individuals who are unable to adequately reduce their dietary salt intake and still continue to gain large amounts of weight between dialysis, and are resistant to reducing their pre-dialysis weight, calcium antagonists may help to lower BP, either alone or in combination with RAS blockade. However, the BP often remains resistant to treatment unless they can be persuaded to reduce their salt intake.

Key Words: haemodialysis • blood pressure • extracellular fluid volume • salt intake • renin-angiotensin system

References

• Ezzati M., Lopez AD, Rodgers A. et al. Selected major risk factors and global and regional burden of disease. Lancet 2002; 360:1347-60.[CrossRef][Web of Science][Medline] [Order article via Infotrieve]
• Foley RN, Parfrey PS, Sarnak MJ Epidemiology of cardiovascular disease in chronic renal disease. J Am Soc Nephrol 1998;9:S16-S23.[CrossRef][Medline] [Order article via Infotrieve]
• Mittal SK, Kowalski E.,Trenkle J. et al. Prevalence of hypertension in a hemodialysis population. Clin Nephrol 1999;51: 77-82.[Web of Science][Medline] [Order article via Infotrieve]
• Salem MM Hypertension in the hemodialysis population: a survey of 649 patients. Am J Kidney Dis 1995;26(3):461-8. 5. Charra B., Calemard E., Ruffet M. et al. Survival as an index of adequacy of dialysis. Kidney Int 1992;41:1286-91.[Web of Science][Medline] [Order article via Infotrieve]
• Tomita J., Kimura G., Inoue T. et al. Role of systolic BP in determining prognosis of hemodialyzed patients.AmJKidney Dis 1995;25:405-12.
• De Lima JJG, Vieira MLC,Abensur H. et al. Baseline blood pressure and other variables influencing survival on haemodialysis of patients without overt cardiovascular disease. Nephrol Dial Transplant 2001;16:793-7.[Abstract/Free Full Text]
• Zager PG, Nikolic J., Brown RH et al. `U` curve association of blood pressure and mortality in hemodialysis patients. Kidney Int 1998;54:561-9.[CrossRef][Web of Science][Medline] [Order article via Infotrieve]
• Foley RN, Parfrey PS, Harnett JD et al. Impact of hypertension on cardiomyopathy, morbidity and mortality in end-stage renal disease. Kidney Int 1996;49:1379-85.[Web of Science][Medline] [Order article via Infotrieve]
• Iseki K., Miyasato F., Tokuyama K. et al. Low diastolic blood pressure, hypoalbuminaemia, and risk of death in a cohort of chronic hemodialysis patients. Kidney Int 1997;51:1212-17.[Web of Science][Medline] [Order article via Infotrieve]
• Port RK, Hulbert-Shearon TE,Wolfe RA et al. Predialysis blood pressure and mortality risk in a national sample of maintenance hemodialysis patients. Am J Kidney Dis 1999;33:507-17.[Web of Science][Medline] [Order article via Infotrieve]
• Foley RN, Parfrey PS Cardiovascular disease and mortality in end-stage renal disease. J Nephrology 1998;11:239-45.
• Tomson CRV. Advising dialysis patients to restrict fluid intake without restricting sodium intake is not based on evidence and is a waste of time. Nephrol Dial Transplant 2001; 16;1538-42.[Free Full Text]
• He FJ, Markandu ND, MacGregor GA Importance of the renin system for determining blood pressure fall with acute salt restriction in hypertensive and normotensive whites. Hypertension 2001;38:321-5.[Abstract/Free Full Text]
• Singer DRJ, Markandu ND, Buckley MG et al. Contrasting endocrine responses to acute oral compared with intravenous sodium loading in normal humans. Am J Physiol 1998;274: F111-F119.[Web of Science][Medline] [Order article via Infotrieve]
• Cappuccio FP, Markandu ND, Sagnella GA et al. Sodium restriction lowers high blood pressure through a decreased response of the renin system - direct evidence using Saralasin. J Hypertens 1985;3:243-7.[CrossRef][Web of Science][Medline] [Order article via Infotrieve]
• MacGregor GA, Markandu ND, Roulston JE et al. The reninangiotensin-aldosterone system in the maintenance of blood pressure, aldosterone secretion and sodium balance in normotensive subjects. Clin Sci 1980;59:S95-S99.[Web of Science]
• MacGregor GA, Markandu ND, Singer DRJ et al. Moderate sodium restriction with angiotensin converting enzyme inhibitor in essential hypertension: a double blind study. BMJ 1987;294:531-4.[Abstract/Free Full Text]
• Weidmann P., Beretta-Piccoli C., Steffen F. et al. Hypertension in terminal renal failure. Kidney Int 1976;9:294301.
• Zuchelli P., Santoro A., Zuccala A. Genesis and control of hypertension in haemodialysis patients. Semin Nephrol 1988; 8:163-7.[Web of Science][Medline] [Order article via Infotrieve]
• Rosen SM, Robinson PJA. Interdependence of exchangeable sodium and plasma renin concentration in determining blood pressure in patients treated by maintenance dialysis. BMJ 1973;4:139-43.[Abstract/Free Full Text]
• Kimura G.,Takahashi N., KawanoY. et al. Plasma renin activity in hemodialyzed patients during long-term follow-up. Am J Kidney Dis 1995;25:589-92.[CrossRef][Web of Science][Medline] [Order article via Infotrieve]
• Lins LE, Hedenborg G., Jacobson SH et al. Blood pressure reduction during hemodialysis correlates to intradialytic changes in plasma volume. Clin Nephrol 1992;37:308-13.[Web of Science][Medline] [Order article via Infotrieve]
• Katzarski KS, Nisell J., Randmaa I. et al. A critical evaluation of ultrasound measurement of inferior vena cava diameter in assessing dry weight in normotensive and hypertensive hemodialysis patients. Am J Kidney Dis 1997;30:459-65.[Web of Science][Medline] [Order article via Infotrieve]
• Zuchelli P., Santoro A., Zuccala A. Genesis and control of hypertension in haemodialysis patients. Semin Nephrol 1988; 8:163-7.[Web of Science][Medline] [Order article via Infotrieve]
• Katzarski KS, Charra B., Luik AJ et al. Fluid state and blood pressure control in patients treated with long and short haemodialysis. Nephrol Dial Transplant 1999;14:369-75.[Abstract/Free Full Text]
• Dionisio P., Valenti M., Bergia R. et al. Influence of the hydration state on blood pressure values in a group of patients on regular maintenance hemodialysis. Blood Purif 1997;15:25-33.[Web of Science][Medline] [Order article via Infotrieve]
• Lins RL, Elseviers M., Rogiers P. et al. Importance of volume factors in dialysis related hypertension. Clin Nephrol 1997;48: 29-33.[Web of Science][Medline] [Order article via Infotrieve]
• Rahman M., Fu P., Seghal AR et al. Intradialytic weight gain, compliance with dialysis regimen, and age are independent predictors of blood pressure in haemodialysis patients. Am J Kidney Dis 2000;35:257-65.[Web of Science][Medline] [Order article via Infotrieve]
• Rahman M., DixitA, Donley V. et al. Factors associated with inadequate blood pressure control in hypertensive haemodialysis patients. Am J Kidney Dis 1999;33:498-506.[Web of Science][Medline] [Order article via Infotrieve]
• Coomer RW, Schulman G., Breyer JA et al. Ambulatory blood pressure monitoring in dialysis patients and estimation of mean interdialytic blood pressure. Am J Kidney Dis 1997; 29:678-84.[Web of Science][Medline] [Order article via Infotrieve]
• Savage T., Fabbian F., Giles M. et al. Interdialytic weight gain and 48-hr blood pressure in haemodialysis patients. Nephrol Dial Transplant 1997;12:2308-11.[Abstract/Free Full Text]
• LuikAJ, Gladziwa U., Kooman JP et al. Influence of interdialytic weight gain on blood pressure in hemodialysis patients. Blood Purif 1994;12:259-66.[Web of Science][Medline] [Order article via Infotrieve]
• Vertes V., Cangiano JL, Berman LB et al. Hypertension in end-stage renal disease.NEnglJMed 1969;280:978-81.[Web of Science][Medline] [Order article via Infotrieve]
• Brown JJ, Curtis JR, Lever AF et al. Plasma renin concentration and the control of blood pressure in patients on maintenance haemodialysis.Nephron 1969;6:329-49.[Web of Science][Medline] [Order article via Infotrieve]
• Wilkinson R., Scott DF, Uldall PR et al. Plasma renin and exchangeable sodium in the hypertension of chronic renal failure. Q J Med 1970;155:377-94.
• Weidmann P., Maxwell MH, Lupu AN et al. Plasma renin activity and blood pressure in terminal renal failure. N Engl J Med 1971;285:757-62.[Web of Science][Medline] [Order article via Infotrieve]
• Davies DL, Beevers DG, Briggs JD et al. Abnormal relation between exchangeable sodium and the renin-angiotensin system in I malignant hypertension and hypertension with chronic renal failure. Lancet 1973;1:683-6.[Medline] [Order article via Infotrieve]
• Rosen SM, Robinson PJA. Interdependence of exchangeable sodium and plasma renin concentration in determining blood pressure Iin patients treated by maintenance dialysis. BMJ 1973;4:139-43.[Abstract/Free Full Text]
• Luik AJ, Van Kuijk WHM, Spek J. et al. The effects of hypervolaemia on interdialytic hemodynamics and blood pressure control in hemodialysis patients. Am J Kidney Dis 1997;30: 466-74.[CrossRef][Web of Science][Medline] [Order article via Infotrieve]
• Igarashi Y., Suzuki H., Imafuku T. et al. Hypertension in patients on chronic hemodialysis: The role of the renin-angiotensin system. Jap Circ J 1987;51:479-84.[Medline] [Order article via Infotrieve]
• VenturaJE, Sposito M. Volume sensitivity of blood pressure in end-stage renal disease. Nephrol Dial Transplant 1997;12: 485-91.[Abstract/Free Full Text]
• De Wardener HE, MacGregor GA Blood pressure and in kidney. In: Schrier RW, Gottschalk CW (eds.). Diseases of the Kidney. Sixth edition. New York: Little, Brown and Co, 1997;2: 1303-26
• Textor SC, Gavras H., Tifft CP, Bernard DB, Idelson B., Brunner HR Norepinephrine and renin activity in chronic renal failure: evidence for interacting roles in haemodialysis hypertension. Hypertension 1981;3:294-9.[Abstract/Free Full Text]
• Krautzig S., Janssen U., Koch KM et al. Dietary salt restriction and reduction of dialysate sodium to control hypertension in maintenance haemodialysis patients. Nephrol Dial Transplant 1998;13:552-3.[Free Full Text]
• Ozkahya M., Toz H., Unsal A. et al. Treatment of hypertension in dialysis patients by ultrafiltration: role of cardiac dilatation an time factor.AmJKidney Dis 1999;34:218-21.
• Ozkahya M., Toz H., Ozerkan F. et al. Impact of volume control on left ventricular hypertrophy in dialysis patients. J Nephrol 2002;15:655-60.[Web of Science][Medline] [Order article via Infotrieve]
• Rigby-Matthews A., Scribner BH,Ahmad S. Control on interdialytic weight gain does not require fluid restriction in hemodialysis patients. J Am Soc Nephrol 1999;10:267A.
• Maduell F., Navarro V. Assessment of salt intake in hemodialysis.Nefrologia 2001;21:71-7.[Web of Science][Medline] [Order article via Infotrieve]
• Farmer CKT, Donohoe P., Dallyn P. et al. Low-sodium hemodialysis without fluid removal improves blood pressure control in chronic dialysis patients. Nephrology 2000;5:237-41. 51. Charra B., Bergstrom J., Scribner BH Blood pressure control in dialysis patients; the importance of the lag phenomenon. Am J Kidney Dis 1998;32:720-4.[Web of Science][Medline] [Order article via Infotrieve]
• LuikAJ, Charra B., Katzarski K. et al. Blood pressure control and hemodynamic changes in patients on long dialysis treatment time. Blood Purif 1998;16:197-209.[CrossRef][Web of Science][Medline] [Order article via Infotrieve]
• Luik AJ, Van Der Sande FM, Weideman P. et al. The influence of increasing dialysis time and reducing dry weight on blood pressure control in haemodialysis patients:A prospective study. Am J Nephrol 2001; 21:471-8.[CrossRef][Web of Science][Medline] [Order article via Infotrieve]
• Vallance P., Leone A., Calver A. et al. Accumulation of an endogenous inhibitor of nitric oxide synthesis in chronic renal failure. Lancet 1992;339:572-5.[CrossRef][Web of Science][Medline] [Order article via Infotrieve]
• Spangler WL Pathophysiologic response of the juxtaglomerular apparatus to dietary sodium restriction in the dog. Am J Vet Res 1979;40:808-09.
• Robertson JIS. Renin with anorexia nervosa, bulimia nervosa, vomiting and abuse of diuretics and purgatives. In: Robertson JIS, Nicholls MG (eds.). The Renin-Angiotensin System. London: Gower Medical Publishing, 1993;2:72.1-72.4
• Horl MP, Horl WH Hemodialysis-associated hypertension: pathophysiology and therapy. Am J Kidney Dis 2002;39:227-44.[CrossRef][Web of Science][Medline] [Order article via Infotrieve]
• D'Amico M., Locatelli F. Hypertension in dialysis: pathophysiology and treatment. J Nephrol 2002;15:438-45.[Web of Science][Medline] [Order article via Infotrieve]
• Mailloux LU, Haley WE Hypertension in the ESRD patient: pathophysiology, therapy, outcomes and future directions. Am J Kidney Dis 1998;32:705-19.[Web of Science][Medline] [Order article via Infotrieve]
• Ritz E., Koomans HA New insights into mechanisms of blood pressure regulation in patients with uraemia. Nephrol Dial Transplant 1996;11:52-9.[Abstract]
• Converse RL,Jacobsen TN,Toto RD et al. Sympathetic over activity in patients with chronic renal failure. N Engl J Med 1992;327:1912-18.[Abstract]
• Tuncel M., Augustyniak R., Zhang W. et al. Sympathetic nervous system function in renal hypertension. Curr Hypertens Reports 2002;4:229-36.[Web of Science][Medline] [Order article via Infotrieve]
• Lightenberg G., Blankestijn PJ, Oey PL et al. Reduction of sympathetic hyperactivity by enalapril in patients with chronic renal failure.NEnglJMed 1999;340:1321-8.[Abstract/Free Full Text]
• Cheigh JS, Milite C., Sullivan JF et al. Hypertension is not adequately controlled in hemodialysis patients. Am J Kidney Dis 1992;19:453-9.[Web of Science][Medline] [Order article via Infotrieve]
• London GM, Marchais SJ, Guerin AP et al. Salt and water retention and calcium blockade in uremia. Circulation 1990; 82:105-13.[Abstract/Free Full Text]
• Blacher J., Guerin AP, Pannier B. et al. Impact of aortic stiffness on survival in end-stage renal disease. Circulation 1999; 18:2434-9.
• Safar ME, Thuilliez C., Richard V. et al. Pressure-independent contribution of sodium to large artery structure and function in hypertension. Cardiovasc Res 2000;46:269-76.[Abstract/Free Full Text]
• Avolio AP, Clyde KM, Beard TC et al. Improved arterial distensibilty in normotensive subjects on a low salt diet. Arteriosclerosis 1986;6:166-9.[Abstract/Free Full Text]
• Avolio AP, Deng FQ, Li WQ et al. Effects of aging on arterial distensibility in populations with high and low prevalence of hypertension: comparison between urban and rural communities in China. Circulation 1985;71:202-10.[Abstract/Free Full Text]
• London GM, Marchais SJ, Guerin AP et al. Cardiac hypertrophy and arterial alterations in end-stage renal disease: hemodynamic factors. Kidney Int 1993;43:S42-S49.[Web of Science]
• Parfrey PS, Foley RN, Harnett JD et al. Outcome and risk factors for left ventricular disorders in chronic uraemia. Nephrol Dial Transplant 1996;11:1277-85.[Abstract/Free Full Text]
• Silberberg JS, Barre PE, Prichard SS et al. Impact of left ventricular hypertrophy on survival in end-stage renal disease. Kid Int 1989;36:286-90.[Web of Science][Medline] [Order article via Infotrieve]
• London GM, Pannier B., Guerin AP et al. Alterations of left ventricular hypertrophy in and survival of patients receiving hemodialysis: follow-up of an interventional study. J Am Soc Nephrol 2001;12:2759-67.[Abstract/Free Full Text]
• Perry IJ, Beevers DG Salt intake and stroke: a possible direct effect. J Hum Hypertens 1992;6:23-5.[Web of Science][Medline] [Order article via Infotrieve]
• HOPE Study Investigators. Effects of an angiotensin-converting-enzyme inhibitor, ramipril, on cardiovascular events in high-risk patients. NEngJMed 2000;342:145-53.
• The SOLVD Investigators. Effect of enalapril on survival in patients with reduced left ventricular ejection fractions and congestive heart failure. N Eng J Med 1991;325:293-302.[Abstract]
• Efrati S., Zaidenstein R., Dishy V. et al. ACE inhibitors and survival of hemodialysis patients. Am J Kidney Dis 2002; 40:1023-9.[CrossRef][Web of Science][Medline] [Order article via Infotrieve]
• Dyadyk AI, Bagriy AE, Lebed IA et al. ACE inhibitors captopril and enalapril induce regression of left ventricular hypertrophy in hypertensive patients with chronic renal failure. Nephrol Dial Transplant 1997;12:945-51.[Abstract/Free Full Text]
• Canella G., Paoletti E., Delfino R. et al. Prolonged therapy with ACE inhibitors induces a regression of left ventricular hypertrophy of dialyzed uremic patients independently from hypotensive effects. Am J Kidney Dis 1997;30:659-64.[Web of Science][Medline] [Order article via Infotrieve]
• Shibasaki Y., Masaki H., Nishiue T. et al. Angiotensin II Type 1 receptor antagonist, losartan, causes regression of left ventricular hypertrophy in end-stage renal disease. Nephron 2002; 90:256-61.[CrossRef][Web of Science][Medline] [Order article via Infotrieve]
• Zannad F., Kessler M., Gunfeld JP et al. FOSIDIAL: a randomised placebo controlled trial of the effects of fosinopril on cardiovascular mortality and mortality in haemodialysis patients. Study design and patients' baseline characteristics. Fund Clin Pharm 2002;16:353-60.
• Oldenburg B., MacDonald GJ, Shelley S. Controlled trial of enalapril in patients with chronic fluid overload undergoing dialysis. BMJ 1988;296:1089-91.[Abstract/Free Full Text]
• Macdougall ICThe role of ACE inhibitors and angiotensin II receptor blockers in the response to epoetin. Nephrol Dial Transplant 1999;14:1836-41.[Free Full Text]
• Schiffl HS, Lang SM Angiotensin-converting enzyme inhibitors but not angiotensin II AT 1 receptor antagonists affect erythropoesis in patients with anaemia of end-stage renal disease. Nephron 1999; 81:106-08.[CrossRef][Web of Science][Medline] [Order article via Infotrieve]
• Schaefer RM, Schaefer L., Horl WH Anaphylactoid reactions during hemodialysis. Clin Nephrol 1994;42(suppl 1):S44-S47.[Web of Science][Medline] [Order article via Infotrieve]
• Knoll GA, Sahgal A., Nair RC et al. Renin-angiotensin system blockade and the risk of hyperkalaemia in chronic hemodialysis patients. Am J Med 2002;112:110-14.[CrossRef][Web of Science][Medline] [Order article via Infotrieve]

Journal of Renin-Angiotensin-Aldosterone System, Vol. 5, No. 1, 14-22 (2004)
DOI: 10.3317/jraas.2004.001


CiteULike    Complore    Connotea    Del.icio.us    Digg    Reddit    Technorati    Twitter    What's this?

This Article Abstract Free Full Text (Free PDF) Free Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Saved Citations Download to citation manager Request Permissions Request Reprints Add to My Marked Citations Citing Articles Citing Articles via Google Scholar Citing Articles via Scopus Google Scholar Articles by Doulton, T. W. Articles by MacGregor, G. A Search for Related Content PubMed PubMed Citation Articles by Doulton, T. W. Articles by MacGregor, G. A Pubmed/NCBI databases Substance via MeSH Medline Plus Health Information Dialysis Dietary Sodium Kidney Failure Social Bookmarking                         What's this?