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

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. 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. During the past decade, mounting evidence has highlighted blood pressure (BP) and volume status as key mediators of outcomes among individuals receiving maintenance dialysis.1Weiner D.E. Brunelli S.M. Hunt A. et al.Improving clinical outcomes among hemodialysis patients: a proposal for a "volume first" approach from the chief medical officers of US dialysis providers.Am J Kidney Dis. 2014; 64: 685-695Abstract Full Text Full Text PDF PubMed Google Scholar, 2Zoccali C. Moissl U. Chazot C. et al.Chronic fluid overload and mortality in ESRD.J Am Soc Nephrol. 2017; 28: 2491-2497Crossref PubMed Scopus (90) Google Scholar, 3Assimon M.M. Wenger J.B. Wang L. et al.Ultrafiltration rate and mortality in maintenance hemodialysis patients.Am J Kidney Dis. 2016; 68: 911-922Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar, 4Flythe J.E. Xue H. Lynch K.E. et al.Association of mortality risk with various definitions of intradialytic hypotension.J Am Soc Nephrol. 2015; 26: 724-734Crossref PubMed Scopus (119) Google Scholar, 5Assimon M.M. Wang L. Flythe J.E. Failed target weight achievement associates with short-term hospital encounters among individuals receiving maintenance hemodialysis.J Am Soc Nephrol. 2018; 29: 2178-2188Crossref PubMed Scopus (4) Google Scholar, 6Hecking M. Moissl U. Genser B. et al.Greater fluid overload and lower interdialytic weight gain are independently associated with mortality in a large international hemodialysis population.Nephrol Dial Transplant. 2018; 33: 1832-1842Crossref PubMed Scopus (12) Google Scholar Qualitative data suggest that suboptimal BP and volume management negatively affect quality of life.7Evangelidis N. Tong A. Manns B. et al.Developing a set of core outcomes for trials in hemodialysis: an international Delphi survey.Am J Kidney Dis. 2017; 70: 464-475Abstract Full Text Full Text PDF PubMed Scopus (64) Google Scholar, 8Flythe J.E. Dorough A. Narendra J.H. et al.Perspectives on symptom experiences and symptom reporting among individuals on hemodialysis.Nephrol Dial Transplant. 2018; 33: 1842-1852Crossref PubMed Scopus (4) Google Scholar, 9Cox K.J. Parshall M.B. Hernandez S.H.A. et al.Symptoms among patients receiving in-center hemodialysis: a qualitative study.Hemodial Int. 2017; 21: 524-533Crossref PubMed Scopus (12) Google Scholar Efforts to develop consensus best practices in managing BP and volume in dialysis have been hampered by an absence of widely available, accurate, and objective measures of extracellular volume status, as well as a lack of high-quality evidence. As such, related practice patterns vary considerably, both within local communities and throughout the world. In February 2019, Kidney Disease: Improving Global Outcomes (KDIGO) held a Controversies Conference, Blood Pressure and Volume Management in Dialysis, in Lisbon, Portugal (https://kdigo.org/conferences/bp-volume-management-in-dialysis/). The conference is the second of 4 conferences planned on dialysis (see Chan et al.10Chan C.T. Blankestijn P.J. Dember L.M. et al.Dialysis initiation, modality choice, access, and prescription:conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference.Kidney Int. 2019; 96: 37-47Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar for the first report, on dialysis initiation). Participants, who included both physicians and patients, considered how BP and volume management can be optimized and individualized across dialysis modalities and resource settings. As participants addressed specific issues relating to BP and volume in dialysis, multiple crosscutting themes emerged. First was the substantial heterogeneity of the dialysis population (e.g., incident vs. prevalent status, comorbid conditions, residual kidney function [RKF], and nutritional status) and the treatment setting (in-center vs. home therapies, medication use, etc.) that must be considered when prescribing dialysis. Second was the ever-present tension in balancing multiple, interlinked, volume-related factors within a narrow therapeutic window for avoiding complications (Figure 1). In some instances, correcting one volume-related abnormality (e.g., hypervolemia) may result in increasing risk associated with another volume-related parameter (e.g., ultrafiltration [UF] rate and RKF). Data to guide these decisions are limited. Third was recognition of the impact that poorly managed BP and volume have on patient lives, and the importance of incorporating patient priorities into management decisions. Fourth, availability of local resources and technologies vary globally and often dictate the bounds of dialysis prescriptions. Therefore, individualizing the dialysis prescription to manage BP and volume for each patient and setting is essential and requires incorporating numerous factors into decision-making. Finally, there was broad-based recognition of the lack of quality evidence to inform recommendations for the management of many of the BP and volume complications discussed, resulting in few strong recommendations, and calls for additional research. In many regions of the world, the dialysis community is well positioned to fill these knowledge gaps. Investigators and dialysis organizations must collaborate to leverage the predictable nature of dialysis treatments, large volumes of collected data, and research and clinical implementation capacities inherent to well-resourced dialysis delivery systems to address these fundamental questions. The diagnosis and management of hypertension in patients receiving hemodialysis (HD) are often based on pre- and post-dialysis BP measurements.11National Kidney FoundationK/DOQI clinical practice guidelines for cardiovascular disease in dialysis patients.Am J Kidney Dis. 2005; 45: S1-S153Abstract Full Text Full Text PDF Google Scholar However, assessment of cardiovascular risk based on these measurements may be not be fully informed, as observational studies have shown that pre- and post-dialysis BP have either no association or a U- or J-shaped association with mortality.12Foley R.N. Herzog C.A. Collins A.J. et al.Blood pressure and long-term mortality in United States hemodialysis patients: USRDS Waves 3 and 4 Study.Kidney Int. 2002; 62: 1784-1790Abstract Full Text Full Text PDF PubMed Scopus (265) Google Scholar, 13Robinson B.M. Tong L. Zhang J. et al.Blood pressure levels and mortality risk among hemodialysis patients in the Dialysis Outcomes and Practice Patterns Study.Kidney Int. 2012; 82: 570-580Abstract Full Text Full Text PDF PubMed Scopus (80) Google Scholar, 14Jhee J.H. Park J. Kim H. et al.The optimal blood pressure target in different dialysis populations.Sci Rep. 2018; 8: 14123Crossref PubMed Scopus (2) Google Scholar These findings may stem in part from the inaccuracy of pre- and post-dialysis BP measurements. Pre- and post-dialysis BPs, even if measured using a standardized protocol, are imprecise estimates of interdialytic BPs15Sarafidis P.A. Mallamaci F. Loutradis C. et al.Prevalence and control of hypertension by 48-h ambulatory blood pressure monitoring in haemodialysis patients: a study by the European Cardiovascular and Renal Medicine (EURECA-m) working group of the ERA-EDTA.Nephrol Dial Transplant. 2018; 33: 1872Crossref PubMed Scopus (3) Google Scholar,16Agarwal R. Peixoto A.J. Santos S.F. et al.Pre- and postdialysis blood pressures are imprecise estimates of interdialytic ambulatory blood pressure.Clin J Am Soc Nephrol. 2006; 1: 389-398Crossref PubMed Scopus (142) Google Scholar and generally should not be used alone for diagnosing and managing hypertension. However, pre-, post- (i.e., peridialytic), and intradialytic BP measurements do have clinical importance for assessing and managing hemodynamic stability during the HD session. Ambulatory BP monitoring is considered the gold-standard method for BP evaluation.17Parati G. Ochoa J.E. Bilo G. et al.Hypertension in chronic kidney disease part 1: Out-of-office blood pressure monitoring: Methods, thresholds, and patterns.Hypertension. 2016; 67: 1093-1101Crossref PubMed Scopus (28) Google Scholar, 18Agarwal R. Flynn J. Pogue V. et al.Assessment and management of hypertension in patients on dialysis.J Am Soc Nephrol. 2014; 25: 1630-1646Crossref PubMed Scopus (72) Google Scholar, 19Sarafidis P.A. Persu A. Agarwal R. et al.Hypertension in dialysis patients: a consensus document by the European Renal and Cardiovascular Medicine (EURECA-m) working group of the European Renal Association-European Dialysis and Transplant Association (ERA-EDTA) and the Hypertension and the Kidney working group of the European Society of Hypertension (ESH).Nephrol Dial Transplant. 2017; 32: 620-640PubMed Google Scholar Compared with peridialytic BP, 44-hour interdialytic BP has superior risk prediction for all-cause and cardiovascular mortality.20Alborzi P. Patel N. Agarwal R. Home blood pressures are of greater prognostic value than hemodialysis unit recordings.Clin J Am Soc Nephrol. 2007; 2: 1228-1234Crossref PubMed Scopus (143) Google Scholar,21Agarwal R. Blood pressure and mortality among hemodialysis patients.Hypertension. 2010; 55: 762-768Crossref PubMed Scopus (154) Google Scholar Ambulatory BP monitoring use may be limited by patient intolerance, availability, and financial constraints in some countries.19Sarafidis P.A. Persu A. Agarwal R. et al.Hypertension in dialysis patients: a consensus document by the European Renal and Cardiovascular Medicine (EURECA-m) working group of the European Renal Association-European Dialysis and Transplant Association (ERA-EDTA) and the Hypertension and the Kidney working group of the European Society of Hypertension (ESH).Nephrol Dial Transplant. 2017; 32: 620-640PubMed Google Scholar When ambulatory BP monitoring is unavailable, home BP measurements may be taken twice a day, covering interdialytic days over 1–2 weeks or twice a day for 4 days following the midweek treatment.19Sarafidis P.A. Persu A. Agarwal R. et al.Hypertension in dialysis patients: a consensus document by the European Renal and Cardiovascular Medicine (EURECA-m) working group of the European Renal Association-European Dialysis and Transplant Association (ERA-EDTA) and the Hypertension and the Kidney working group of the European Society of Hypertension (ESH).Nephrol Dial Transplant. 2017; 32: 620-640PubMed Google Scholar,22Agarwal R. Light R.P. Chronobiology of arterial hypertension in hemodialysis patients: implications for home blood pressure monitoring.Am J Kidney Dis. 2009; 54: 693-701Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar Compared with peridialytic BP measurement in HD, home BP measurement has superior agreement with mean 44-hour ambulatory BP monitoring,23Agarwal R. Andersen M.J. Bishu K. et al.Home blood pressure monitoring improves the diagnosis of hypertension in hemodialysis patients.Kidney Int. 2006; 69: 900-906Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar higher short-term reproducibility,24Agarwal R. Satyan S. Alborzi P. et al.Home blood pressure measurements for managing hypertension in hemodialysis patients.Am J Nephrol. 2009; 30: 126-134Crossref PubMed Scopus (0) Google Scholar and improved prediction of adverse outcomes.20Alborzi P. Patel N. Agarwal R. Home blood pressures are of greater prognostic value than hemodialysis unit recordings.Clin J Am Soc Nephrol. 2007; 2: 1228-1234Crossref PubMed Scopus (143) Google Scholar,21Agarwal R. Blood pressure and mortality among hemodialysis patients.Hypertension. 2010; 55: 762-768Crossref PubMed Scopus (154) Google Scholar Key disadvantages of home BP monitoring are the absence of information on nocturnal dipping, and in some settings, cost. A third alternative is BP measurement in-office, not in the dialysis unit. Increased systolic BPs (SBPs) outside of the dialysis unit are an independent risk factor for mortality.25Bansal N. McCulloch C.E. Rahman M. et al.Blood pressure and risk of all-cause mortality in advanced chronic kidney disease and hemodialysis: the chronic renal insufficiency cohort study.Hypertension. 2015; 65: 93-100Crossref PubMed Scopus (70) Google Scholar Another alternative is mean or median peridialytic BP (pre-, inter-, and post-HD BP values), which has greater sensitivity and specificity in detecting interdialytic hypertension than pre- or post-dialysis BP measurements alone.26Agarwal R. Metiku T. Tegegne G.G. et al.Diagnosing hypertension by intradialytic blood pressure recordings.Clin J Am Soc Nephrol. 2008; 3: 1364-1372Crossref PubMed Scopus (54) Google Scholar However, no studies have assessed the association of this approach with outcomes. Data assessing the validity of peridialytic, office, and home BP in patients receiving home HD or peritoneal dialysis (PD) are limited, and no studies have been conducted in these populations on the associations of out-of-unit BP measurements and the risk of cardiovascular outcomes. Research to identify valid methods for BP measurement in all dialysis modalities is recommended (Table 1).Table 1Research recommendationsaResearch recommendations within each topic area are listed in order of priority, stratified by modality type.ModalityRecommendationsBP measurements, targets, and pathophysiology HD and PDInvestigate the optimal BP target/threshold for hypertension treatment HD and PDAssess the agreement and prediction of standardized (attended or unattended) in-office BP readings, averaged intradialytic BP readings, and scheduled home BP readings with ABPM and clinical outcomes HD and PDAssess the acceptability and feasibility of ABPM HD and PDInvestigate strategies to reduce BP variabilityBP agent selection HD and PDHypertension: Conduct head-to-head RCTs of different medication classes on BP, including 44-h ABPM, and clinical and patient-reported outcomes (i.e., ARB vs. BB or ARB vs. BB vs. CCB) HD and PDHypertension: Conduct RCTs on the effect of diuretics on RKF, BP, and CV outcomes HDHypotension: Conduct larger, longer RCTs on effectiveness of midodrineDialysis prescription HD and PDPerform studies that incorporate patient preferences and test individualized treatment approaches HD and PDCompare outcomes of strategies that focus on volume control vs. those that focus on RKF preservation HD and PDHDInvestigate strategies for preserving RKF, including:•Impact of incremental dialysis on RKF•Impact of frequent/long hours dialysis on RKF HD and PDInvestigate whether routine monitoring of RKF impacts clinical outcomes HD and PDInvestigate spot biomarkers and urine volume for simple assessment of RKF HDAssess how to establish an individualized, safe UF rate for patients with different risk profiles HDInvestigate the roles of dialysate composition—sodium, magnesium, and calcium—in intradialytic hypotension PDEvaluate whether minimizing dialysate glucose is preferable to reducing antihypertensive medication in PD patients with hypotension PDAssess whether routine monitoring of peritoneal membrane function impacts clinical outcomesTechnologies HD and PDInvestigate whether bioimpedance-guided volume management improves patient-centered and hard clinical outcomes HD and PDInvestigate whether lung ultrasound-guided volume management improves patient-centered and hard clinical outcomes HDInvestigate whether blood volume monitoring, temperature cooling, hemodiafiltration, UF profiling, and isolated UF have a benefit in hemodynamic stability, and whether this translates into benefits in hard outcomesVolume-related patient symptoms and experiences HD and PDCollect data on quality of life and symptoms in all future studies related to BP and/or volume management HD and PDInvestigate the underlying physiology of symptoms27Salerno F.R. Parraga G. McIntyre C.W. Why is your patient still short of breath? Understanding the complex pathophysiology of dyspnea in chronic kidney disease.Semin Dial. 2017; 30: 50-57Crossref PubMed Scopus (6) Google Scholar HD and PDTest different approaches to routine symptom assessment (e.g., smartphones, tablets) HD and PDInvestigate correlations between symptoms and intradialytic or ambulatory BP, imaging (e.g., ultrasound, cardiac magnetic resonance), cerebral blood flow measurements, and bioimpedance spectroscopy HD and PDDevelop symptom surveys that utilize computerized adaptive testing to decrease burden and tailor questions to individual patient prioritiesABPM, ambulatory blood pressure monitoring; ARB, angiotensin receptor blocker; BB, ß-blocker; BP, blood pressure; CCB, calcium channel blocker; CV, cardiovascular; HD, hemodialysis; PD, peritoneal dialysis; RCT, randomized controlled trial; RKF, residual kidney function; UF, ultrafiltration.a Research recommendations within each topic area are listed in order of priority, stratified by modality type. Open table in a new tab ABPM, ambulatory blood pressure monitoring; ARB, angiotensin receptor blocker; BB, ß-blocker; BP, blood pressure; CCB, calcium channel blocker; CV, cardiovascular; HD, hemodialysis; PD, peritoneal dialysis; RCT, randomized controlled trial; RKF, residual kidney function; UF, ultrafiltration. Accepted definitions of hypertension and BP treatment targets in the dialysis population have not been determined, with just one relevant randomized controlled trial (RCT). The Blood-Pressure-in-Dialysis pilot (BID) study randomized 126 participants to either an intensive pre-dialysis SBP goal of 110–140 mm Hg or a standard SBP goal of 155–165 mm Hg, with the primary objective of assessing feasibility and safety to inform a larger RCT assessing hard clinical outcomes.28Miskulin D.C. Gassman J. Schrader R. et al.BP in dialysis: results of a pilot study.J Am Soc Nephrol. 2018; 29: 307-316Crossref PubMed Scopus (13) Google Scholar The study demonstrated intervention feasibility; however, despite the protocol calling for site investigators to challenge post-dialysis weight as the initial step in attaining the assigned target SBP, the intensive SBP goal was achieved by use of additional antihypertensive medications. Target weights actually increased in the intervention group, suggesting inadequate management of the extracellular volume status. No population-specific evidence has established BP thresholds and targets for interdialytic BP (i.e., not pre- or post-dialysis) for the dialysis population. Extrapolating from current general population hypertension guidelines may be reasonable, but such guidelines do not account for differences in cardiovascular risk in dialysis patients. Specifically, numerous observational studies12Foley R.N. Herzog C.A. Collins A.J. et al.Blood pressure and long-term mortality in United States hemodialysis patients: USRDS Waves 3 and 4 Study.Kidney Int. 2002; 62: 1784-1790Abstract Full Text Full Text PDF PubMed Scopus (265) Google Scholar, 13Robinson B.M. Tong L. Zhang J. et al.Blood pressure levels and mortality risk among hemodialysis patients in the Dialysis Outcomes and Practice Patterns Study.Kidney Int. 2012; 82: 570-580Abstract Full Text Full Text PDF PubMed Scopus (80) Google Scholar, 14Jhee J.H. Park J. Kim H. et al.The optimal blood pressure target in different dialysis populations.Sci Rep. 2018; 8: 14123Crossref PubMed Scopus (2) Google Scholar and the Blood-Pressure-in-Dialysis study28Miskulin D.C. Gassman J. Schrader R. et al.BP in dialysis: results of a pilot study.J Am Soc Nephrol. 2018; 29: 307-316Crossref PubMed Scopus (13) Google Scholar have suggested harm from lower BPs. Targeting too low of a threshold may heighten cardiovascular risk in some patients. The 2017 American College of Cardiology/American Heart Association Guidelines29Whelton P.K. Carey R.M. Aronow W.S. et al.2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.Hypertension. 2018; 71: e13-e115Crossref PubMed Google Scholar BP threshold and target is 130/80 mm Hg; in contrast, the 2018 European Society of Hypertension/European Society of Cardiology Guidelines30Williams B. Mancia G. Spiering W. et al.2018 ESC/ESH Guidelines for the Management of Arterial Hypertension: The Task Force for the Management of Arterial Hypertension of the European Society of Cardiology and the European Society of Hypertension: The Task Force for the Management of Arterial Hypertension of the European Society of Cardiology and the European Society of Hypertension.J Hypertens. 2018; 36: 1953-2041Crossref PubMed Scopus (926) Google Scholar recommend an SBP target of <130 mm Hg for ages <65 years, and an SBP target range of 130–140 mm Hg for all others. Based on existing evidence, definitive recommendations regarding BP treatment targets cannot be made. An individualized approach is a priori necessary for all patients receiving dialysis, with a particular focus on avoiding overly low BPs, and special consideration regarding intradialytic and interdialytic BP patterns, volume management, and ccomorbidities. In a typical dialysis treatment session, BP decreases from pre- to post-dialysis; the magnitude of this reduction most closely relates to the magnitude of UF.19Sarafidis P.A. Persu A. Agarwal R. et al.Hypertension in dialysis patients: a consensus document by the European Renal and Cardiovascular Medicine (EURECA-m) working group of the European Renal Association-European Dialysis and Transplant Association (ERA-EDTA) and the Hypertension and the Kidney working group of the European Society of Hypertension (ESH).Nephrol Dial Transplant. 2017; 32: 620-640PubMed Google Scholar Intradialytic hypotension is a serious complication of HD, associated with vascular access thrombosis, inadequate dialysis dose, and mortality.4Flythe J.E. Xue H. Lynch K.E. et al.Association of mortality risk with various definitions of intradialytic hypotension.J Am Soc Nephrol. 2015; 26: 724-734Crossref PubMed Scopus (119) Google Scholar,31Chang T.I. Paik J. Greene T. et al.Intradialytic hypotension and vascular access thrombosis.J Am Soc Nephrol. 2011; 22: 1526-1533Crossref PubMed Scopus (32) Google Scholar,32Shoji T. Tsubakihara Y. Fujii M. et al.Hemodialysis-associated hypotension as an independent risk factor for two-year mortality in hemodialysis patients.Kidney Int. 2004; 66: 1212-1220Abstract Full Text Full Text PDF PubMed Scopus (381) Google Scholar Intradialytic hypotension prevalence ranges from 15% to 50% of HD treatments, depending on the definition (Table 2).Table 2Definitions of intradialytic hypotension and intradialytic hypertensionGuideline definitionOther definitions and notesSuggested definitionIntradialytic hypotensionKDOQI 2005 Guidelines11National Kidney FoundationK/DOQI clinical practice guidelines for cardiovascular disease in dialysis patients.Am J Kidney Dis. 2005; 45: S1-S153Abstract Full Text Full Text PDF Google Scholar Decrease in SBP ≥ 20 mm Hg or mean BP ≥ 10 mm Hg with associated symptoms (cramping, headache, lightheadedness, vomiting, or chest pain) or need for intervention (reduction in UF or administration of fluids)•SBP drop accompanied by interventions (saline bolus administration, UF reduction, or blood pump flow reduction)•SBP drop of a certain degree (20, 30, or 40 mm Hg)•Nadir intradialytic SBP below a threshold value (90, 95, or 100 mm Hg)A nadir SBP < 90 mm Hg and a nadir SBP < 100 mm Hg in patients with pre-dialysis SBP > 160 mm Hg is most potently associated with mortality.4Flythe J.E. Xue H. Lynch K.E. et al.Association of mortality risk with various definitions of intradialytic hypotension.J Am Soc Nephrol. 2015; 26: 724-734Crossref PubMed Scopus (119) Google ScholarAny symptomatic decrease in SBP or a nadir intradialytic SBP < 90 mm Hg should prompt reassessment of BP and volume management.Intradialytic hypertensionNone•BP rise of any degree during the second or third intradialytic hour•SBP rise > 15 mm Hg within or immediately post-dialysis•SBP rise > 10 mm Hg from pre- to post-dialysis•Rising intradialytic BP that is unresponsive to volume removalAn SBP rise >10 mm Hg from pre- to post-dialysis in the hypertensive range in at least 4 of 6 consecutive dialysis treatments should prompt a more extensive evaluation of BP and volume management, including home and/or ABPM.ABPM, ambulatory blood pressure monitoring; BP, blood pressure; KDOQI, National Kidney Foundation Kidney Disease Outcomes Quality Initiative; SBP, systolic blood pressure; UF, ultrafiltration. Open table in a new tab ABPM, ambulatory blood pressure monitoring; BP, blood pressure; KDOQI, National Kidney Foundation Kidney Disease Outcomes Quality Initiative; SBP, systolic blood pressure; UF, ultrafiltration. Any symptomatic decrease in BP or a nadir intradialytic SBP of <90 mm Hg should prompt reassessment of BP management. This reassessment includes, but is not limited to, UF rate, dialysis treatment time, interdialytic weight gain (IDWG), dry-weight estimation, and antihypertensive medication use, in concordance with discussions in the following sections. Avoidance of intradialytic hypotension should not come at the expense of maintaining euvolemia or ensuring adequate dialysis time. Data on intradialytic hypotension during home HD or intermittent PD techniques are scarce. Intradialytic hypertension is the phenomenon of BP increase during or immediately after a dialysis session, and it involves activation of the sympathetic nervous and renin–angiotensin systems, endothelial stiffness, volume excess, and other mechanisms.33Inrig J.K. Intradialytic hypertension: a less-recognized cardiovascular complication of hemodialysis.Am J Kidney Dis. 2010; 55: 580-589Abstract Full Text Full Text PDF PubMed Scopus (84) Google Scholar,34Georgianos P.I. Sarafidis P.A. Zoccali C. Intradialysis hypertension in end-stage renal disease patients: clinical epidemiology, pathogenesis, and treatment.Hypertension. 2015; 66: 456-463Crossref PubMed Scopus (14) Google Scholar Intradialytic hypertension has an estimated prevalence of 5%–15%, depending on the definition used (Table 2). Defining it as an SBP increase of >10 mm Hg from pre- to post-dialysis accurately identifies persons with persistently elevated interdialytic BP35Bikos A. Angeloudi E. Memmos E. et al.A comparative study of short-term blood pressure variability in hemodialysis patients with and without intradialytic hypertension.Am J Nephrol. 2018; 48: 295-305Crossref PubMed Scopus (0) Google Scholar and de