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A Journal on Nephrology and Urology

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Minerva Urologica e Nefrologica 2002 March;54(1):37-43

language: English

Hypertension in end-stage renal disease

Appleby C., Foley R. N.

From the Directorate of Renal Medicine Hope Hospital Salford Royal Hospitals NHS Trust Salford, United Kingdom


Chron­ic ­renal fail­ure is com­mon. ­Recent esti­mates ­from the Unit­ed ­States sug­gest ­that one in 10 ­adults has an ele­vat­ed ser­um crea­ti­nine. Hyper­ten­sion and ­renal dis­ease are inti­mate­ly con­nect­ed at ­many lev­els, and clear­ly accel­er­ate ­each ­other’s ­course. Hyper­ten­sion is an ­almost uni­ver­sal fea­ture of end-­stage ­renal dis­ease, a state of fright­en­ing car­di­o­vas­cu­lar ­risk. Sur­pris­ing­ly, ­most ­recent obser­va­tion­al stud­ies ­have ­shown an asso­ci­a­tion ­between low ­blood pres­sure and ­increased mor­tal­ity, a ­result ­that may engen­der ther­a­peu­tic nihi­lism in the ­absence of ­large ran­dom­ised ­trials. ­This obser­va­tion may be due to ­reverse cau­sal­ity, as the age and car­di­o­vas­cu­lar comor­bid­ity of ­patients reach­ing end-­stage ­renal dis­ease is con­sid­er­able. ­When out­comes oth­er ­than ­death are con­sid­ered, espe­cial­ly pro­gres­sive ­left ven­tric­u­lar hyper­tro­phy, but ­also ischaem­ic ­heart dis­ease and con­ges­tive ­heart fail­ure, ­more pre­dict­able and expect­ed asso­ci­a­tions are ­seen, ­with ris­ing ­blood pres­sure appear­ing to be a del­e­ter­i­ous param­e­ter. Urae­mia ­appears to be a ­state of pre­ma­ture senes­cence, and arte­ri­al rigid­ity, ­whose clin­i­cal cor­ol­lary is ­wide ­pulse pres­sure, is a char­ac­ter­is­tic fea­ture. ­Recent obser­va­tion­al stud­ies ­have ­focused on ­pulse pres­sure, rath­er ­than the tra­di­tion­al ­approach of ana­lys­ing its com­po­nents, sys­tol­ic and dia­stol­ic ­blood pres­sure, in iso­la­tion. ­High ­pulse pres­sure ­appears to be a mark­er of ­short sur­vi­val in dial­y­sis ­patients, but dis­en­tan­gling ­this asso­ci­a­tion ­from old age and pre-exist­ing car­di­o­vas­cu­lar con­di­tions is chal­leng­ing. Remark­ably, and regret­tably, no ­large ­scale ran­dom­ised con­trolled stud­ies exam­in­ing strat­e­gies ­that tack­le the ­issue of hyper­ten­sion in dial­y­sis ­patients ­have yet to be initiat­ed.

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