Ultrafiltration intensification for achievement of dry weight and hypertension control is not always the therapeutic gold standard

Abstract

Extracellular volume excess is an important factor in the pathogenesis of arterial hypertension, and control of volume status by ultrafiltration and achievement of dry weight is considered as an essential therapeutical approach. In the present issue of the Journal of Nephrology, Curatola and coworkers present challenging data indicating that ultrafiltration intensification improves hypertension control but increases the risks for cardiovascular events, with peripheral arteriopathy as the principal complication. This is another challenge for determination of dry weight on the basis of blood pressure (BP) measurement. The reference BP is brachial blood pressure. Brachial blood pressure is lower than limb BP. In normal conditions, lower-limb BP (ankle blood pressure) is higher than brachial BP, and the so-called ankle-brachial systolic pressure index is between 0.9 and 1.3. An ankle-brachial index <0.90 indicates the presence of lower-limb arteriopathy, and it should be measured systematically in end-stage renal disease (ESRD) patients because a large proportion of these patients present asymptomatic peripheral arteriopathies. In these conditions, taking into account brachial BP to determine dry weight and BP control can lead to a decline in the perfusion pressure of the lower limbs, with dramatic clinical consequences. The study by Curatola et al (J Nephrol, 2011, present issue) illustrates that the therapeutic approach to cardiovascular risk and hypertension in ESRD patients is still challenging. It underlines the necessity of considering the pathophysiology and mechanisms associated with cardiovascular risk, instead of systematically applying a generally accepted "gold standard" approach.