Blood pressure in chronic kidney disease stage 5D—report from a Kidney Disease: Improving Global Outcomes controversies conference

Management of blood pressure (BP) in patients with chronic kidney disease receiving dialysis (stage 5D) provides a significant challenge for healthcare professionals. The association between BP and cardiovascular disease risk has been well studied in the general population; however, in dialysis patients, physiological and dialysis-related mechanisms influencing BP are complex, and the associated risk is poorly understood. In stage 5D, BP is determined by the complex interplay of fluid volume and prescription of post-dialysis target weight, sodium load, the renin–angiotensin and sympathetic nervous systems, and diverse exogenous factors, such as administration of erythropoiesis-stimulating agents, the type and timing of administration of antihypertensive drugs, and dialysate composition. Management of BP in this population requires both generally applicable plans and individualization in order to determine the BP target and the treatment regimen. This report summarizes the deliberations and recommendations of a conference sponsored by the Kidney Disease: Improving Global Outcomes (KDIGO) to address the following questions: (1) what is the optimal BP treatment target in relation to end-organ damage and outcomes in dialysis patients; (2) how should antihypertensive drugs be used in dialysis patients; and (3) what nonpharmacological therapies can be considered in achieving BP targets? The conference report will augment the KDIGO clinical practice guideline on blood pressure in chronic kidney disease stages 1–5, which is currently under development.