Narrative Review
Challenges in Blood Pressure Measurement in Patients Treated With Maintenance Hemodialysis

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The association between blood pressure and cardiovascular outcomes in patients undergoing hemodialysis remains controversial. This may relate in part to the technique and device used and the timing of the blood pressure measurement in relation to the hemodialysis procedure. Emerging evidence indicates that standardized hemodialysis unit blood pressure measurements or measurements obtained at home, either by the patient or using an ambulatory blood pressure monitor, may offer advantages over routine hemodialysis unit blood pressure measurements for determining cardiovascular risk and treatment. This review discusses the available evidence and implications for clinicians and clinical trials.

Section snippets

Devices and Techniques for Measuring BP

BP measurements in the hemodialysis unit are performed on multiple occasions for the purpose of volume assessment and safety. National29 and international30 hypertension guidelines describe the appropriate devices, cuff sizes, and technique of measurement of BP.

Reliability, Agreement, and Validity of BP Measurements

The time that BP is measured in relation to the hemodialysis procedure may influence the clinical interpretation of the measurement because there is variability within individual hemodialysis patients and different clinical associations with different measurements and a lack of agreement between BPs measured within and outside the hemodialysis unit.

Which Type of BP Measurement Should Clinicians Use to Initiate and Monitor Treatment?

Accepting that there are limitations in the evidence for decreasing BP in patients receiving hemodialysis and that a target BP for any measure is yet to be defined, clinicians should consider a shift in practice away from assessment of routine hemodialysis-unit BPs, although these remain important for managing the dialysis procedure. In particular, the guideline recommendations to use a routine single prehemodialysis BP measurement to make clinical decisions should be reconsidered (Table 3).

Conclusion

Routine BP measurements performed in the hemodialysis unit are often used to inform clinical decisions, but have significant limitations. Increasing data indicate that BP measurements performed outside the hemodialysis unit or standardized BP measurements in the hemodialysis unit increase reliability. The former may have stronger clinical associations than routine hemodialysis-unit BPs. Although harder to obtain, these measurements should be considered in clinical management and clinical

Acknowledgements

The BLOCADE Feasibility Study Trial Management Committee consists of: Matthew Roberts and Frank Ierino (Austin Health and University of Melbourne); Nicole Isbel (Princess Alexandra Hospital and University of Queensland); Henry Krum (Monash University); Carmel Hawley (Princess Alexandra Hospital, Australasian Kidney Trials Network, and University of Queensland); Alan Cass (The George Institute for Global Health, and University of Sydney); Helen Pilmore (Auckland City Hospital); Andrew Tonkin

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    Originally published online June 12, 2012.

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    A list of the members of the BLOCADE Feasibility Study Trial Management Committee appears in the Acknowledgements.

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    Copyright © 2012 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.