Hypertension in the ESRD patient: Pathophysiology, therapy, outcomes, and future directions

Cardiovascular disease remains the leading cause of death in the end- stage renal disease (ESRD), chronic renal failure, and transplant patient population. The majority of dialysis patients begin renal replacement therapy with a disproportionate cardiovascular disease risk factor burden, eg, premature atherosclerosis, hypertensive vascular disease, nonhypertensive left ventricular dysfunction, hyperlipidemia, age, and so on. Each of these accelerates the other. This report will review hypertension in the ESRD patient population. The Joint Clinical Practices Committee of the Renal Physicians Association and the American Society of Nephrology was asked to develop an evidence-based clinical practice guideline for the treatment of hypertension in chronic renal failure and the ESRD patient, to be presented to the Health Care Financing Administration (HCFA). The group was also asked to identify areas for future study and prepare an up-to-date bibliography in the field. Based on an in-depth review of the literature, the committee concluded that not enough data were available to submit an evidence-based clinical practice guideline. Thus, a treatment algorithm was not provided to the HCFA. This manuscript, based on the scientific data for the report to the HCFA, is an in-depth review of the literature on hypertension in the ESRD patient. Pathogenesis, relation to outcome, clinical therapeutic guidelines, and areas for future study are discussed. In addition, the separate exhaustive bibliography (obtainable from the National Kidney Foundation) for hypertension, renal disease, and dialysis should be a valuable resource to all nephrologists interested in clinical practice and research.