Management of Patient Care in Hemodialysis While Focusing on Cardiovascular Disease Events and the Atypical Role of Hyper- and/or Hypotension: A Systematic Review

Table 1

Conclusive summary of the full-text articles included in qualitative synthesis ().

S #	Reference	Title	Conclusion
1	Gorsane et al. 2015 [31]	“Prevalence and Risk Factors of Hypertension in Hemodialysis”	The reduction of BP allows a lower risk of CV events and mortality in HTN patients.
2	Diaz et al. 2015 [29]	“Mortality and Intradialytic Hypertension and Hypotension Episodes”	Intradialytic hypertension/hypotension episodes are major risk factors for mortality with a high percentage of probable causality. The use of beta blockers and calcium channel blockers may confer protection in avoiding increased mortality. Finally the development of cardiomegaly is increased significantly in these patients and may lead to cardiac events.
3	Chao et al. 2015 [24]	“Intradialytic Hypotension and Cardiac Remodeling: A Vicious Cycle”	A bidirectional relationship might exist between intradialytic hypotension and left ventricular hypertrophy in chronic dialysis patients. A more complete understanding of the complex interactions in between could assist the readers in formulating potential solutions for the reduction of both phenomena.
4	Iseki 2015 [32]	“Control of Hypertension and Survival in Hemodialysis Patients”	HTN is risk and must be controlled.
5	Enam et al. 2014 [33]	“Management of Hypertension in the Hemodialysis Population: A Review of the Literature”	Multiple management modalities may benefit.
6	Agarwal et al. 2014 [34]	“Assessment and Management of Hypertension in Patients on Dialysis”	Often medication directed approaches are used; however, no pharmacologic and dialytic approaches are more likely to be successful and may target one of the major factors that contribute to the development of congestive heart failure. So more clinical trials are needed.
7	Jablonski and Chonchol 2014 [35]	“Recent Advances in the Management of Hemodialysis Patients: A Focus on Cardiovascular Disease”	Morbidity and mortality in maintenance hemodialysis patients are extremely high, and management of care is complex. Treatment options for reducing CVD events, mortality, or both in maintenance hemodialysis are currently limited, and future randomized controlled trials related to each of these points should be considered, with the goal of ultimately improving hard outcomes.
8	Inrig 2013 [36]	“Peri-Dialytic Hypertension and Hypotension: Another U-Shaped BP-Outcome Association”	This study describes the relationship between pre- and postdialysis changes in BP and mortality. The study demonstrated adverse outcomes associated both with large decreases and with any increase in blood pressure pre- to postdialysis.
9	Roberts et al. 2012 [37]	“Challenges in Blood Pressure Measurement in Patients Treated with Maintenance Hemodialysis”	Emerging evidence indicates that standardized hemodialysis unit blood pressure measurements or measurements obtained at home, either by the patient or using an ambulatory blood pressure monitor, may offer advantages over routine hemodialysis unit blood pressure measurements for determining cardiovascular risk and treatment.
10	Altun et al. 2012 [38]	“Prevalence, Awareness, Treatment and Control of Hypertension in Adults with Chronic Kidney Disease in Turkey: Results from the CREDIT Study”	HTN is high risk/awareness to control is essential.
11	Chang 2011 [39]	“Systolic Blood Pressure and Mortality in Patients on Hemodialysis”	The association of SBP with clinical outcomes in patients on hemodialysis is complex. With annual mortality rates for patients on hemodialysis approaching 20% and over half of all these deaths being attributable to cardiovascular causes, future clinical trials that will elucidate ways to improve outcomes for these highest-risk patients are desperately needed.
12	Singapuri and Lea 2010 [40]	“Management of Hypertension in the End-Stage Renal Disease Patient”	Vigorous control of hypertension is recommended.
13	Peixoto and Santos 2010 [41]	“Blood Pressure Management in Hemodialysis: What Have We Learned?”	Until more research is available, we should manage hypertension in hemodialysis with the use of conservative targets, aggressive pursuit of euvolemia through dry weight probing and limitation of sodium overload, and judicious use of medications from conventional drug classes.
14	Malliara 2007 [42]	“The Management of Hypertension in Hemodialysis and CAPD Patients”	The relationship of hypertension with adverse outcomes is uncertain in the hemodialysis population. Whether control of hypertension translates into better outcomes is not known, but collective evidence suggests that hypertension should be controlled in hemodialysis patients.
15	Stidley et al. 2006 [43]	“Changing Relationship of Blood Pressure with Mortality over Time among Hemodialysis Patients”	The relationship between baseline BP and mortality changes over time. High systolic BP (>150 mmHg) was associated with increased mortality among patients who survived >3 years. Low pulse pressure was associated with increased mortality. Mild to moderate systolic hypertension was associated with only modest increases in mortality.
16	Agarwal and Andersen 2006 [44]	“Blood Pressure Recordings within and outside the Clinic and Cardiovascular Events in Chronic Kidney Disease”	Ambulatory BP monitoring in patients with CKD adds to our ability to predict cardiovascular end-points, over and above in-clinic BPs. Risk factors that differentiate hypertension or nondipping appear to confer a cardiovascular risk in CKD.
17	Agarwal et al. 2006 [45]	“Pre- and Postdialysis Blood Pressures Are Imprecise Estimates of Interdialytic Ambulatory Blood Pressure”	Dialysis unit BP measurements are imprecise estimates.
18	Saint-Remy and Krzesinski 2005 [46]	“Optimal Blood Pressure Level and Best Measurement Procedure in Hemodialysis Patients”	Management of BP is necessary in the HD population, first by slow and smooth removal of extracellular volume (dry weight) and thereafter by the use of appropriate antihypertensive medication.
19	Agarwal 2005 [47]	“Hypertension and Survival in Chronic Hemodialysis Patients—Past Lessons and Future Opportunities”	Relationship exists between HTN, CV, and total mortality.
20	Agarwal 2005 [48]	“Hypertension in Chronic Kidney Disease and Dialysis: Pathophysiology and Management”	Confounding variables, such as heart failure, can help explain the U-shaped relationship between BP and total mortality. Well-controlled BP in the presence of poor cardiac function is likely to be associated with high cardiovascular mortality. In contrast, poorly controlled BP with intact cardiac function is expected to be associated with increased mortality. If patients with impaired cardiac function constitute a large part of an observational cohort, a U-shaped relationship between BP and total mortality is seen.
21	Boutitie et al. 2002 [49]	“J-Shaped Relationship between Blood Pressure and Mortality in Hypertensive Patients: New Insights from a Meta-Analysis of Individual-Patient Data”	The increased risk for events observed in patients with low blood pressure was not related to antihypertensive treatment and was not specific to blood pressure-related events. Poor health conditions leading to low blood pressure and an increased risk for death probably explain the J-shaped curve.
22	Mitra et al. 1999 [50]	“What is Hypertension in Chronic Hemodialysis? The Role of Interdialytic Blood Pressure Monitoring”	Hypertension in chronic HD patients contributes significantly to morbidity and mortality. The best representation of interdialytic BP was 20 min postdialysis reading. Walk-in predialysis BP overestimates mean interdialytic BP due to a high incidence of white-coat effect. Ambulatory monitoring has a role in evaluating persistent poor BP control in HD patients.
23	Zager et al. 1998 [17]	““U” Curve Association of Blood Pressure and Mortality in Hemodialysis Patients”	A “U” curve relationship exists between systolic blood pressure and cardiovascular mortality in hemodialysis patients. Multicentered, randomized, controlled clinical trials are required for establishing optimal BP targets in HD patients.