Hypertension (HT) is present in more than 80% of patients undergoing Hemodialysis (HD).
Elevated Blood Pressure (BP) in hemodialysis patients is associated with cardiovascular events and
mortality only when BP is recorded with home or ambulatory monitoring, since pre- and post-dialysis
measurements are not valid estimates of BP levels during the interdialytic interval. Sodium and water
overload is the most important of several mechanisms involved in HT development in HD. In this context,
non-pharmacologic measures to ensure water and sodium balance by achieving patient dry weight
and decreasing daily sodium intake, through modification of sodium level in the diet or in dialysis
dialysate, are fundamental for HT control. After these strategies are properly implemented, the introduction
of drug treatment can further help in achieving optimum BP. All major antihypertensive classes,
with the exception of diuretics, can be considered in HT management, as current evidence suggest that
the use of agents from these classes was associated with reduced cardiovascular risk. The choice of a
specific antihypertensive drug should be based on the co-morbid conditions of the patient, and the pharmacologic
characteristics of the agent, including dialyzability. Of note, the need of increasing the number of
antihypertensive drugs, should be each time balanced against reappraisal of the non-pharmacologic measures,
as increased antihypertensive efficacy can result in a vicious circle of more difficulties regarding dry
weight reduction, possible volume overload, and further BP increase.