Blood Pressure and Cardiovascular Risk in the Dialysis Patient
How Low Can You Go?
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See related article, pp 435–443
Cardiovascular disease is the leading cause of death in patients with chronic renal failure receiving hemodialysis.1 Arterial hypertension is highly prevalent among hemodialysis patients, affecting at least 80% of this patient population.2 Based on the plethora of evidence demonstrating the key role of arterial hypertension as a cardiovascular risk factor in all nondialysis-dependent patients, extending this framework to hemodialysis patients seems undisputable.1 However, despite the widespread recognition of its prevalence, adequate control of hypertension is achieved in only a small fraction of hemodialysis patients, with ≈70% being either untreated or treated inadequately.3 In addition to the distinctive pathophysiology of hypertension in hemodialysis patients, a pervasive reluctance to aggressively treat hypertension in this population seems to contribute to the observed lack of adequate blood pressure (BP) control. This common practice has largely been justified by multiple observational studies indicating a U-shaped association between BP and all-cause mortality in hemodialysis patients, in sharp contrast to the linear association found in the general population.4–7 This reverse epidemiology is framed by the findings that lower BP levels carry a high risk of mortality while the lowest risk is conferred by BP levels well within the hypertensive range applicable to the general population. Although numerous explanations for these puzzling findings have been proposed, it has recently become apparent that only …