Pathophysiology and Treatment of Hypertension in Dialysis Patients

  • August Heidland
  • Roland M. Schaefer
Conference paper
Part of the Advances in Experimental Medicine and Biology book series (AEMB, volume 260)


Before the start of regular dialysis treatment (RDT) the prevalence of hypertension averages between 75 and 90%l,2. During long-term RDT its prevalence declines markedly. The resulting inverse relationship between duration of RDT and elevated blood pressure (BP) is not only caused by the early death of hypertensive patients, but mainly due to the antihypertensive effect of dialysis itself. This BP-lowering effect relates only to hypertensive but not normotensive patients. In a 10-year follow-up study the percentage of hypertensive patients declined from 73 to 16%3. Hypertension disappeared in younger individuals, while it persisted or developed de-novo in older patients, showing the characteristics of systolic hypertension. This observation underlines the role of age-related factors in the pathogenesis of this type of hypertension. Interestingly, the prevalence of hypertension after 10 years of dialysis was lower than the prevalence in an age- and sex-matched population 4. In these patients, besides fluid and salt removal by dialysis, a decrease in the dry weight, observed in many patients after 5 years of dialysis treatment, may contribute to the BP-lowering effect. It appears that prolonged dialysis sessions up to 24 to 30 hours per week lead to a more effective control of blood pressure. In a 10-year follow-up study on 52 patients performed by Charra5 normotension was achieved by strict maintenance of dry weight alone (low salt diet, but no antihypertensive drugs).


Chronic Renal Failure Dialysis Patient Beta Blocker Chronic Hemodialysis Patient Renal Anemia 
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  1. 1.
    Lazarus, J. M., Hampers, C. C. and Merrill, J. P., 1974, Hypertension in chronic renal failure. Treatment with hemodialysis and nephrectomy, Arch. Intern. Med., 133:1050.CrossRefGoogle Scholar
  2. 2.
    Weidmann, P. and Maxwell, M. H. 1975, The renin-angiotensin-aldosterone system in terminal renal failure, Kidney Int., 8:219.CrossRefGoogle Scholar
  3. 3.
    Degli Esposti, E., Boero, R., Chiarini, C., Nagroni, D., Quarello, F., Santoro, A., Sturani, A., Zuccala, A., Piccoli, G. and Zucchelli, P., 1983, Blood pressure behaviour in hemodialysis patients treated for 10 years, Int. J. Artif. Organs, Vol. 6:121PubMedGoogle Scholar
  4. 4.
    Bellettini, W., Francesconi, F., Bentivogli, M., Cremonini, G. , Marchetta, F., Viscanti, G. , Autore, A., Bonaiuto, S., Cantadori, L and Piatteli, A., 1976, Contributo allo studio epidemiologico dell’ipertensione arteriosa in provincia di Bologna, Caratteristiche generali, Osp. Vita 6:52Google Scholar
  5. 5.
    Charra, B., Calemard, E., Cuche, M. and Laurent, G., 1983, Control of hypertension and prolonged survival on maintenance hemodialysis, Nephron, 33:96PubMedCrossRefGoogle Scholar
  6. 6.
    Sellars, L., Robson, V. and Wilkinson, R., 1979, Sodium retention and hypertension with short dialysis, Br. med. J. i:520CrossRefGoogle Scholar
  7. 7.
    Levin, N.W. and Grondin, G., 1978, Dialysate sodium concentration, Int. J. artif. Organs, 1:255PubMedGoogle Scholar
  8. 8.
    Langer, K., Raidt, H., Chu, W.T. and Graefe, U., 1988 Drugs prescribed in chronic hemodialysis patients: A multicenter report, EDTA/ERA Congress Madrid, Abstract p. 178Google Scholar
  9. 9.
    Batlle, D.C., von Riotte, A. and Lang, G., 1986, Delayed hypotensive response to dialysis in hypertensive patients with end-stage renal disease, Am. J. Nephrol., 6:14PubMedCrossRefGoogle Scholar
  10. 10.
    Baumgart, P., Lison, A.E., Gemen, S., Walger, P., Graefe, U. and Rahn, K.H., 1988, Ambulatory 24 h-blood pressure monitoring n renal failure, hemodialysis and after kidney transplantation, EDTA/ERA Congress Madrid, Abstract p. 85Google Scholar
  11. 11.
    Vincenti, F., Amend, W.J., Abele, J., Feduska, N.J. and Salviatierra, O.Jr, 1980, The role of hypertension in hemodialysis associated atherosclerosis, Am. J. Med., 68:363PubMedCrossRefGoogle Scholar
  12. 12.
    Leunissen, K.M.L., van den Berg, B.W., Noordzij, T.C., Slaaf, D. W. and van Hoof, J. P., 1988, Capillary morphology in chronic hemodialysis patients, EDTA/ERA Congress Madrid, Abstract p. 180Google Scholar
  13. 13.
    Degoulet, P., Legrain, M., Reach, I., Aime, F., Devries, C., Rojas, P. and Jacobs, C., 1982, Mortality risk factors in patients treated by chronic hemodialysis, Nephron, 31:103PubMedCrossRefGoogle Scholar
  14. 14.
    Rostand, S.G., Kirk, K.A. and Rutsky, E.A., 1982, Relationship of coronary risk factors to hemodialysis-associated ischemic heart disease, Kidney Int., 22:304PubMedCrossRefGoogle Scholar
  15. 15.
    Vertes, V., Cangiano, J.L., Berman, L.B. and Gould, A., 1969, Hypertension in end-stage renal disease, New. Engl. J. Med., 280:978PubMedCrossRefGoogle Scholar
  16. 16.
    Guyton, A.C., Coleman, T.G., Young, D.B., Lohmeier, T.E. and DeClue, J.W., 1980, Salt balance and long-term blood pressure control, Ann. Rev. Med., 31: 15PubMedCrossRefGoogle Scholar
  17. 17.
    Blaustein, M.P., 1977, Sodium ions, calcium ions, blood pressure regulation and hypertension: a reassessment and a hypothesis, Am. J. Physiol., 232:C165PubMedGoogle Scholar
  18. 18.
    Graves, S.W., Brown, B. and Valdes, R., 1983, An endogenous digoxin-like substance in patients with renal impairment, Ann. Intern. Med., 99:604PubMedGoogle Scholar
  19. 19.
    Poston, L., Sewell, R.B., Wilkinson, S.P., Richardson, P.J., Williams, R., Clarkson, E.M., MacGregor, G.A. and De Wardener, H.E., 19881, Evidence for a circulating sodium transport inhibitor in essential hypertension, Br. Med. J., 282 (1): 847Google Scholar
  20. 20.
    Schalekamp, M.A., Beevers, D.G., Briggs, J.D., Brown, J.J., Davies, D.L., Fraser, R., Lebel, M., Lever, A.F., Medina, A., Morton, J.J., Robertson, J.I.S. and Tree, M. , 1973, Hypertension in chronic renal failure. An abnormal relation between sodium and the renin-angiotensin system, Am. J. Med., 55: 379PubMedCrossRefGoogle Scholar
  21. 21.
    Klaus, D., 1976, Pathogenesis of renoparenchymal hypertension, in: Renal Insufficiency, Ed. A. Heidland, H. Hennemann, J. Kult, Georg Thieme Stuttgart, 3Google Scholar
  22. 22.
    Weidmann, P., Beretta-Picolli, C., Steffen, F., Blumberg, A. and Reubi, F.C., 1976, Hypertension in terminal renal failure, Kidney Int., 9:294PubMedCrossRefGoogle Scholar
  23. 23.
    Mimran, A., Shaldon, S., Barjou, P. and Mion, C., 1978, The effect of an angiotensin antagonist (Saralasin) on arterial pressure and plasma aldosterone in hemodialysisresistent hypertension patients, Clin. Nephrol., 9:63PubMedGoogle Scholar
  24. 24.
    Katholi, R.E., Wintermits, S.R. and Oparil, S, 1981, Role of the renal nerves in the pathogenesis of onekidney renal hypertension in the rat, Hypertension, 3:404PubMedGoogle Scholar
  25. 25.
    Brecht, H.M., Ernst, W. and Koch, K.M, 1976, Plasma nordrenaline levels in regular haemodialysis patients, Proc. Eur. Dial. Transplant. Assoc., 12:281PubMedGoogle Scholar
  26. 26.
    Naik, R.B., Mathias, C.J., Wilson, C.A., Reid, J.L. and Warren, D.J, 1981, Cardiovascular and autonomic reflexes in haemodialysis patients, Clin. Sci., 60:165PubMedGoogle Scholar
  27. 27.
    Izzo, J.L. Jr., Izzo, M.S., Sterns, R.H. and Freeman, R.B., 1982, Sympathetic nervous system hyperactivity in maintenance hemodialysis patients, Trans. Am. Soc. Artif. Intern. Organs, 28:604PubMedGoogle Scholar
  28. 28.
    Corneille, L., Lachance, S., Demassieux, S. and Carrier, S, 1983, Turnover of free and conjugated serum catecholamines during hemodialysis, Clin. Invest. Med., 6:11PubMedGoogle Scholar
  29. 29.
    Ratge, D., Augustin, R and Wisser, H., 1983, Catecholamines, renin, aldosterone and arterial pressure in patients on chronic hemodialysis treatment, Int. J. Artif. Organs, 6: 255PubMedGoogle Scholar
  30. 30.
    Campese, V.M., Romoff, M.S., Levitan, D., Lane, K. and Massry, S.G., 1981, Mechanisms of autonomic nervous system dysfunction in uremia, Kidney Int., 20:246PubMedCrossRefGoogle Scholar
  31. 31.
    Rauh, W., Hund, E., Sohi, G., Rascher, W., Mehls, O. and Scharer, K., 1983, Vasoactive hormones in children with chronic renal failure, Kidney Int., 24:27CrossRefGoogle Scholar
  32. 32.
    Kettner, A., Goldberg, A., Hagberg, J.,. Delmez, J. and Harter, H., 1984, Cardiovascular and metabolic responses to submaximal exercise in hemodialysis patients, Kidney Int., 26:66PubMedCrossRefGoogle Scholar
  33. 33.
    Hennemann, H., Hevendehl, G., Horler, E. and Heidland, A., 1973, Toxic sympathicopathy in uremia, Proc. Eur. Dial. Transplant. Assoc., 10:166PubMedGoogle Scholar
  34. 34.
    Hennemann, H., 1976, Die urämische Sympathicopathie, Kidney Int., 28:814, Thieme VerlagGoogle Scholar
  35. 35.
    Schohn, D., Weidmann, P., Jahn, H. and Beretta-Piccoli, C., 1985, Norepinephrine-related mechanism in hypertension accompanying renal failure, Kidney Int., 28:814PubMedCrossRefGoogle Scholar
  36. 36.
    Izzo, J.L.Jr., Santarosa, R.P., Larrabee, P.S., Smith, R.J. and Kallay, M.C., 1987, Increased plasma norepinephrine and sympathetic nervous activity in essential hypertensive and uremic humans: effects of Clonidine, J. Cardiovasc. Pharmacol., 10, Suppl.: 12:225Google Scholar
  37. 37.
    Tomiyama, O., Shigai, T., Ideura, T., Tomita, K., Mito, Y., Shinohara, S. and Takeuchi, J., 1980, Baroreflex sensitivity in renal failure, Clin. Sci., 58:21PubMedGoogle Scholar
  38. 38.
    Heidbreder, E., Schafferhans, K. and Heidland, A., 1985, Disturbances of peripheral and autonomic nervous system in chronic renal failure: Effects of hemodialysis and transplantation, Clin. Nephrol., 22:222Google Scholar
  39. 39.
    Sturani, A., Degli Esposti, E., De March, A., Santoro, A., Fuschini, G. , Zuccala, A., Chiarini, C., Glamigni, C. and Zucchelli, P., 1983, Dopaminergic control of sympathetic activity and blood pressure in haemodialysis patients, Proc. Eur. Dial. Transplant. Assoc., 20:156PubMedGoogle Scholar
  40. 40.
    Brodde, O.E. and Daul, A., 1984, Alpha- and beta-adrenoceptor changes in patients on maintenance hemodialysis, Contr. Nephrol., (Karger Basel) 41;99Google Scholar
  41. 41.
    Rascher, W., Schömig, A., Kreye, V.A. and Ritz, E., 1982, Diminished vascular response to noradrenaline in experimental chronic uremia, Kidney Int., 21:20PubMedCrossRefGoogle Scholar
  42. 42.
    Iseki, K., Massry, S.G. and Campese, V.M., 1985, Evidence for a role of PTH in the reduced pressor response to norepinephrine in chronic renal failure, Kidney Int., 28:11PubMedCrossRefGoogle Scholar
  43. 43.
    Weidmann, P., Massry, S.G., Coburn, J.W. et al., 1972, Blood pressure effects of acute hypercalcemia: studies in patients with chronic renal failure, Ann. Intern. Med., 76, 741PubMedGoogle Scholar
  44. 44.
    Vlachakis, N.D., Frederics, R., Velasquez, M. et al., 1982 Sympathetic system function and vascular reactivity in hypercalcemic patients, Hypertension, 4:452PubMedGoogle Scholar
  45. 45.
    Boullin, D.J., 1967, The action of extracellular cations on the release of the sympathetic transmitter from peripheral nerves, J. Physiol., 189:85PubMedGoogle Scholar
  46. 46.
    Henrich, W.L., Hunt, J.M. and Nixon, J.V., 1984, Increased calcium and left ventricular contractility during hemodialysis, New Engl. J. Med., 310:19PubMedCrossRefGoogle Scholar
  47. 47.
    Sica, D.A., Harford, A.M. and Zawada, E.T., 1984, Hypercalcemic hypertension in hemodialysis, Clin. Nephrol., 22: 102PubMedGoogle Scholar
  48. 48.
    Muirhead, E.E., Broos, B., Kosinski, M., Dnaiels, E.G. and Hinman, J.W., 1966, Renomedullary antihypertensive principle in renal hypertension, J. Lab. Clin. Med., 67:778PubMedGoogle Scholar
  49. 49.
    Samtleben, W. , Baldamus, C.A., Bommer, J., Fassbinder, W., Nonnast-Daniel, B. and Gurland, H.J., 1988, Blood pressure changes during treatment with recombinant human erythropoietin, Contr. Nephrol., (Karger Basel) 66:114Google Scholar
  50. 50.
    Frei, U., Nonnast-Daniel, B. and Koch, K.M., 1988, Erythropoietin und Hpyertonie, Klin. Wochenschr., 66:914PubMedCrossRefGoogle Scholar
  51. 51.
    Winearls, C.G., Pippard, M.J., Downing, M.R., Oliver, D.O., Reid, C. and Cotes, M.P., 1986, Effect of human erythropoietin derived from recombinant DNA on the anemia of patients maintained by chronic haemodialysis, Lancet, 11:1175CrossRefGoogle Scholar
  52. 52.
    Schaefer, R.M., Leschke, M., Strauer, B.E. and Heidland, A., 1988, Blood rheology and hypertension in hemodialysis patients treated with erythropoietin, Am. J. Nephrol., 8:449PubMedCrossRefGoogle Scholar
  53. 53.
    Raine, A.E.G., 1988, Hypertension, blood viscosity and cardiovascular morbidity in renal failure: implications of erythropoietin therapy, Lancet, 11:97CrossRefGoogle Scholar
  54. 54.
    Duling, B.R. and Berne, R.M., 1970, Longitudinal gradients in periarteriolar oxygen tensin: A possible mechanism for the participation of oxygen in local regulation of blood flow, Circulation Res., 27:669PubMedGoogle Scholar
  55. 55.
    Duling, B.R. and Pittman, R.N., 1975, Oxygen tension: Dependent or independent variable in local control of blood flow? Fed. Proc., 34:2012PubMedGoogle Scholar
  56. 56.
    Nonnast-Daniel, B., Creutzig, A., Kuhn, K., Bahlmann, J., Reimers, E., Brunkhorst, R., Caspary, L. and Koch, K.M., 1988, Effect of treatment with recombinant human erythropoietin on peripheral haemodynamics and oxygenation, Contr. Nephrol., 66:185Google Scholar
  57. 57.
    Bergström, J., Asaba, H. and Fürst, P. et al., 1976, Dialysis, ultrafiltration and blood pressure, Proc. Eur. Dial. Transplant. Assoc., 13:293Google Scholar
  58. 58.
    D’Amore, T.F., Wauters, J.P., Waeber, B. and Brunner, H.R., 1985, Salt subtraction in patients on maintenance hemodialysis. Efficacy and limitations, Am. J. Nephrol., 5: 275CrossRefGoogle Scholar
  59. 59.
    Hagberg, J.M., Goldberg, A.P., Ehsani, A.A., Heath, G.W., Delmez, J.A. and Harter, H.R., 1983, Exercise training improves hypertension in hemodialysis patients, Am. J. Nephrol., 3:209PubMedCrossRefGoogle Scholar
  60. 60.
    Goldberg, A-0., Geltman, E.M., Gavin, J.R., Carney, R.M., Hagberg, J.M., Delmez, J.A., Naumovich, A., Oldfield, M.H. and Harter, H.R., 1986, Exercise training reduces coronary risk and effectively rehabilitates hemodialysis patients, Nephron, 42:311PubMedCrossRefGoogle Scholar
  61. 61.
    Painter, P.L., Nelson-Worel, J.N., Hill, M.M., Thronbery, D.R., Shelp, W.R., Harrington, A.R. and Weinstein, A.B., 1986, Effects of exercise training during hemodialysis, Nephron, 43:87PubMedCrossRefGoogle Scholar
  62. 62.
    Klooker, P., Bommer, J. and Ritz, E., 1985, Treatment of hypertension in dialysis patients, Blood Puri., 3:15CrossRefGoogle Scholar
  63. 63.
    Lindner, A., Douglas, S.W., Adamson, J.W., 1978, Propranolol effects in long-term hemodialysis patients with renin-dependent hypertension, Ann. Intern. Med., 88:457PubMedGoogle Scholar
  64. 64.
    Meltzer, V.N., Goldberg, A.P., Tindira, C.A., Naumovich, A.D. and Harter, H.R., 1984, Effects of prazosin and propranolol on blood pressure and plasma lipids in patients undergoing chronic hemodialysis, Am. J. Cardiol., 53 (3): 40APubMedCrossRefGoogle Scholar
  65. 65.
    Fink, G.D., Paulo, L.G. and Fisher, J.W., 1975, Effects of beta-adrenergic blocking agents on erythropoietin production in rabbits exposed to hypoxia, Pharmacol. Exp. Ther., 193:176Google Scholar
  66. 66.
    Hrter, H.R., Meltzer, V.N., Tindira, C.A., Naumovich, A.D. and Goldberg, A.P., 1986, Comparison of the effects of prazosin versus propranolol on plasma lipoprotein lipids in patients receiving hemodialyis, Am. J. Med., 80:82CrossRefGoogle Scholar
  67. 67.
    Ausserwinkler, M. and Schmidt, P., 1989, Erfolgreiche Behandlung des “restless legs”-Syndroms bei chronischer Niereninsuffizienz mit Clonidin, Schw. med. Wschr., 119: 184Google Scholar
  68. 68.
    Levitan, D., Massry, S.G., Romoff, M. and Campese, V.M., 1984, Plasma catecholamines and autonomic nervous system function in patients with early renal insufficiency and hypertension: effect of Clonidine, Nephron, 36:24PubMedCrossRefGoogle Scholar
  69. 69.
    Läppchen, J., Ritz, E., Koch, A., Mörl, H., Bommer, J. and Ossenkop, C., Raynaud-Phänomen bei Dialysepatientsn, Dt. med. Wschr., 102:521Google Scholar
  70. 70.
    Heidland, A., Riegel, W., Hörl, W., Weipert, J., Geiger, H. and Heidbreder, E., 1985, Calcium antagonists: hypo tensive and humoral actions in different forms of hypertension, Contrib. Nephrol., (Karger Basel) 49:201PubMedGoogle Scholar
  71. 71.
    Heidland, U., Riegel, W., Heidbreder, E., Hörl, W.H. and Heidland, A., 1986, Calcium antagonists in impaired renal function and hypertension, in: Calcium Antagonsits and Hypertension: Current Status. Ed. J. Rosenthal. Excerpta Medica, Amsterdam, Hong Kong, Princeton, Sydney, Tokyo, 190Google Scholar
  72. 72.
    Riegel, W., Hörl, W.H. and Heidland, A., 1986, Long-term effects of nifedipine on carbohydrate and lipid metabolism in hypertensive hemodialyzed patients, Klin. Wochenschr., 64:1124PubMedCrossRefGoogle Scholar
  73. 73.
    Riegel, W., Hörl, W.H. and Heidland, A., Long-term effects of nifedipine on plasma levels of 25-hydroxyvitamin D and 1,25 Dihydroxyvitamin D in hypertensive hemodialyzed patients, Klin. Wochenschr., 64:1291Google Scholar
  74. 74.
    Baczynski, R., Massry, S.G. and Kohan, R. et al., 1985, Effect of parathyroid hormone on myocardial energy metabolism in the rat, Kidney Int., 27:718PubMedCrossRefGoogle Scholar
  75. 75.
    Vaughan, E.D., Carey, R.M., Ayers, C.R. and Peach, M.J., 1979, Hemodialysis-resistant hypertension: Control with an orally active inhibitor for angiotensin-converting enzyme, J. Clin. Endocrinol. Metab., 48:869PubMedCrossRefGoogle Scholar
  76. 76.
    Wauters, J.P., Waeber, B., Brunner, H.R., Guignard, J.P., Turini, G.A. and Gavras, H., 1981, Uncontrollable hypertension in patients on hemodialysis: long-term treatment with Captopril and salt substraction, Clin. Nephrol., 16: 86PubMedGoogle Scholar
  77. 77.
    Röckel, A. and Heidland, A., 1981, Behandlung ‘therapie-resistenter’ Hypertonieformen mit Captopril, Med. Klin., 76:427PubMedGoogle Scholar
  78. 78.
    Sennesael, J. and Verbeelen, D., 1985, Intra-individual comparison of Captopril and enalapril in patients undergoing regular haemodialysis, Eur. J. Clin. Pharmacol., 30:257CrossRefGoogle Scholar
  79. 79.
    Hirakata, H., Onoyama, K., Hori, K. and Fujishima, M., 1986, Participation of the renin-angiotensin system in the captopril-induced worsening of anemia in chronic hemodialysis patients, Clin. Nephrol., 26:27PubMedGoogle Scholar
  80. 80.
    Kamper, A.L., Nielsen, O.J., Lokkegaard, H. and Strandgaard, S., 1988, Effect of the converting enzyme inhibitor enalapril (E) on hemoglobin (Hb) and plasma erythropoietin (Ep) in patients with chronic renal failure (CRG), EDTA/ ERA Congress Madrid, Abstract p. 208Google Scholar
  81. 81.
    Kilpatrick, J.S., DeVault, G., Abreo, K., Brown, S.T., Bairnsfather, L. and Stevens, L., 1988, Effects of enalapril (En) on blood pressure (BP) control and weight changes in hemodialysis (HD) patients, Kidney Int., 13:299 AGoogle Scholar
  82. 82.
    Oldenburg, B., MacDonald, G.J. and Shelley, S., 1988, Controlled trial of enalapril in patients with chronic fluid overload undergoing dialysis, Br. Med. J., 296:1089CrossRefGoogle Scholar

Copyright information

© Plenum Press, New York 1989

Authors and Affiliations

  • August Heidland
    • 1
  • Roland M. Schaefer
    • 1
  1. 1.Department of Internal Medicine, Division of NephrologyUniv. of WürzburgGermany

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