Blood pressure and volume management in dialysis: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference

Abstract

Blood pressure (BP) and volume control are critical components of dialysis care and have substantial impacts on patient symptoms, quality of life, and cardiovascular complications. Yet, developing consensus best practices for BP and volume control have been challenging, given the absence of objective measures of extracellular volume status and the lack of high-quality evidence for many therapeutic interventions. In February of 2019, Kidney Disease: Improving Global Outcomes (KDIGO) held a Controversies Conference titled Blood Pressure and Volume Management in Dialysis to assess the current state of knowledge related to BP and volume management and identify opportunities to improve clinical and patient-reported outcomes among individuals receiving maintenance dialysis. Four major topics were addressed: BP measurement, BP targets, and pharmacologic management of suboptimal BP; dialysis prescriptions as they relate to BP and volume; extracellular volume assessment and management with a focus on technology-based solutions; and volume-related patient symptoms and experiences. The overarching theme resulting from presentations and discussions was that managing BP and volume in dialysis involves weighing multiple clinical factors and risk considerations as well as patient lifestyle and preferences, all within a narrow therapeutic window for avoiding acute or chronic volume-related complications. Striking this challenging balance requires individualizing the dialysis prescription by incorporating comorbid health conditions, treatment hemodynamic patterns, clinical judgment, and patient preferences into decision-making, all within local resource constraints.

Keywords: hemodialysis; patient-reported outcome measures; peritoneal dialysis; quality of life; residual kidney function.

Figure 1 |. Tension in balancing volume status within a narrow therapeutic window.

RKF, residual kidney function.

Figure 2 |. Contributors to and consequences of blood pressure and volume abnormalities in dialysis.

GI, gastrointestinal; HD, hemodialysis; IDWG, interdialytic weight gain; PD, peritoneal dialysis; UF, ultrafiltration.

Figure 3 |. Conceptual framework for individualizing dialysis prescriptions.

APD, automated peritoneal dialysis; BMI, body mass index; CAPD, continuous ambulatory peritoneal dialysis; GDP, glucose degradation product; HD, hemodialysis; HDF, hemodiafiltration; IDWG, interdialytic weight gain; PD, peritoneal dialysis; RKF, residual kidney function; UF, ultrafiltration.