HypertensionAHA SCIENTIFIC STATEMENTHypertension in Patients Treated With In-CenterMaintenance Hemodialysis:Current Evidenceand Future Opportunities:A Scientific StatementFrom the American Heart AssociationNisha Bansal,MD,MAS,Chair;Nancy T.Artinian,PhD,RN,FAHA;George Bakris,MD,FAHA;Tara Chang,MD;Jordana Cohen,MD;Jennifer Flythe,MD;Janice Lea,MD;Wanpen Vongpatanasin,MD,FAHA;Glenn M.Chertow,MD,FAHA,Vice Chair;on behalf ofthe American Heart Association Council on the Kidney in Cardiovascular Disease;Council on Cardiovascular and Stroke Nursing;and Council on Epidemiology and PreventionABSTRACT:Nearly 500000 individuals are treated with maintenance hemodialysis for kidney failure in the United States.and roughly half will die of cardiovascular causes.Hypertension,an important and modifiable risk factor for cardiovasculardisease,is observed in >80%of patients treated with maintenance hemodialysis.The pathophysiology of hypertension inpatients treated with maintenance hemodialysis is multifactorial and differs from that seen in other patient populations.Factors that contribute to hypertension in patients treated with hemodialysis include volume overload,arterial stiffness,enhanced activity of the sympathetic nervous and renin-angiotensin-aldosterone systems,endothelial dysfunction,and useof erythropoietin-stimulating agents.This scientific statement reviews the current evidence on defining,diagnosing,andtreating hypertension in patients treated with maintenance hemodialysis and highlights opportunities for future investigation,including studies on blood pressure targets and treatment strategies.Key Words:AHA Scientific Statements hypertension kidney renal dialysis renin-angiotensin systemearly 500 000 individuals are treated with mainte-(Modification of Diet in Renal Disease),showed thatnance hemodialysis for kidney failure in the Unitedthe beneficial effects of intensive blood pressure con-States,'and roughly half will die of cardiovasculartrol on mortality are more pronounced among patientscauses.These patients typically undergo the hemodi-with more advanced CKD,although there were few ifalysis procedures 3 to 4 times a week for 3 to 4 hoursany patients with stage 5 CKD and no patients treatedper session.Hypertension,an important and modifiablewith dialysis in these trials.34risk factor for cardiovascular disease,is observed in>80%of patients treated with maintenance hemo-dialysis.'A meta-analysis of 30 randomized clinicalPATHOPHYSIOLOGY OF HYPERTENSIONtrials including >15000 patients showed that moreIN PATIENTS TREATED WITHintensive treatment of hypertension is associated withlower mortality among individuals with hypertensionMAINTENANCE HEMODIALYSISand stage 3 to 4 chronic kidney disease (CKD),withThe pathophysiology of hypertension in patients treatedfew if any patients with stage 5 CKD included in thesewith maintenance hemodialysis is multifactorial and dif-studies.2 More recent meta-analyses of clinical trials,fers from that seen in other patien
