Increased renin- angiotensin system activity (possibly in the presence of increased sodium overload)
Increased sympathetic activity
Increased endothelin-1 to nitric oxide ratio
Uremic toxins (ADMA)
Blood hyperviscosity
Correction of hypoxia- induced vasoconstriction
Increased dialysate sodium
Secondary hyperparathyroidism
Treatment and Prevention
Lifestyle modifications such as weight reduction, dietary modification, sodium restriction, physical activity and moderation of alcohol consumption can reduce systolic blood pressure from 2-14 mm Hg1
Adjustment of target weight on a regular basis. Gradual reduction of interdialytic weight gain over a few weeks using zero sodium balance, salt restriction, longer dialysis or extra dialysis sessions may yield a significant benefit2
Reducing erythropoeitin dose in patients with severe hypertension and withholding of anti-hypertensive medications on the day of dialysis
Nephrectomy in resistant cases
Renal transplantation or conversion to PD
References:
Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL Jr, Jones DW, Materson BJ, Oparil S, Wright JT Jr, Roccella EJ; National Heart, Lung, and Blood Institute Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure; National High Blood Pressure Education Program Coordinating Committee. Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA 289:2560-2572, 2003.
Charra B. ‘Dry weight’ in dialysis: the history of a concept. Nephrol Dial Transplant. 13:1882-1885, 1998
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