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Blood Pressure and Volume Management in Dialysis: Conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controver www.kidney-international.org KDIGO executive conclusions Blood pressure and volume management in dialysis: conclusions from a Kidney Disease: OPEN Improving Global Outcomes (KDIGO) Controversies Conference Jennifer E. Flythe1,2, Tara I. Chang3, Martin P. Gallagher4,5, Elizabeth Lindley6, Magdalena Madero7, Pantelis A. Sarafidis8, Mark L. Unruh9, Angela Yee-Moon Wang10, Daniel E. Weiner11, Michael Cheung12, Michel Jadoul13, Wolfgang C. Winkelmayer14 and Kevan R. Polkinghorne15,16,17; for Conference Participants18 1University of North Carolina Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, UNC School of Medicine, Chapel Hill, North Carolina, USA; 2Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, North Carolina, USA; 3Division of Nephrology, Stanford University School of Medicine, Palo Alto, California, USA; 4George Institute for Global Health, Renal and Metabolic Division, Camperdown, Australia; 5Concord Repatriation General Hospital, Department of Renal Medicine, Sydney, Australia; 6Department of Renal Medicine, Leeds Teaching Hospitals NHS Trust, Leeds, UK; 7Department of Medicine, Division of Nephrology, National Institute of Cardiology “Ignacio Chávez”, Mexico City, Mexico; 8Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece; 9Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA; 10Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong, China; 11William B. Schwartz Division of Nephrology, Tufts Medical Center, Boston, Massachusetts, USA; 12KDIGO, Brussels, Belgium; 13Department of Nephrology, Cliniques universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium; 14Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA; 15Department of Nephrology, Monash Health, Clayton, Melbourne, Australia; 16Department of Medicine, Monash University, Clayton, Melbourne, Australia; and 17Department of Epidemiology and Preventive Medicine, Monash University, Prahan, Melbourne, Australia Blood pressure (BP) and volume control are critical The overarching theme resulting from presentations and components of dialysis care and have substantial impacts discussions was that managing BP and volume in dialysis on patient symptoms, quality of life, and cardiovascular involves weighing multiple clinical factors and risk complications. Yet, developing consensus best practices for considerations as well as patient lifestyle and preferences, BP and volume control have been challenging, given the all within a narrow therapeutic window for avoiding acute absence of objective measures of extracellular volume or chronic volume-related complications. Striking this status and the lack of high-quality evidence for many challenging balance requires individualizing the dialysis therapeutic interventions. In February of 2019, Kidney prescription by incorporating comorbid health conditions, Disease: Improving Global Outcomes (KDIGO) held a treatment hemodynamic patterns, clinical judgment, and Controversies Conference titled Blood Pressure and Volume patient preferences into decision-making, all within local Management in Dialysis to assess the current state of resource constraints. knowledge related to BP and volume management and Kidney International (2020) 97, 861–876; https://doi.org/10.1016/ identify opportunities to improve clinical and patient- j.kint.2020.01.046 reported outcomes among individuals receiving KEYWORDS: hemodialysis; patient-reported outcome measures; peritoneal maintenance dialysis. Four major topics were addressed: BP dialysis; quality of life; residual kidney function measurement, BP targets, and pharmacologic management Copyright ª 2020, International Society of Nephrology. Published by of suboptimal BP; dialysis prescriptions as they relate to BP Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). and volume; extracellular volume assessment and management with a focus on technology-based solutions; and volume-related patient symptoms and experiences. uring the past decade, mounting evidence has high- lighted blood pressure (BP) and volume status as key Correspondence: Jennifer E. Flythe, University of North Carolina Kidney D Center, 7024 Burnett-Womack CB #7155, Chapel Hill, North Carolina 27599- mediators of outcomes among individuals receiving 1–6 7155, USA. E-mail: jfl[email protected]; or Kevan R. Polkinghorne, Depart- maintenance dialysis. Qualitative data suggest that subop- ment of Nephrology, Monash Medical Centre, 246 Clayton Road, Clayton, timal BP and volume management negatively affect quality of – Melbourne, Victoria 3168 Australia. E-mail: [email protected] life.7 9 Efforts to develop consensus best practices in man- 18See Appendix for list of other Conference Participants. aging BP and volume in dialysis have been hampered by an Received 10 October 2019; revised 5 December 2019; accepted 8 absence of widely available, accurate, and objective measures January 2020; published online 8 March 2020 of extracellular volume status, as well as a lack of high-quality Kidney International (2020) 97, 861–876 861 KDIGO executive conclusions JE Flythe et al.: BP and volume control in dialysis: a KDIGO conference report – evidence. As such, related practice patterns vary considerably, a U- or J-shaped association with mortality.12 14 These both within local communities and throughout the world. findings may stem in part from the inaccuracy of pre- and In February 2019, Kidney Disease: Improving Global post-dialysis BP measurements. Pre- and post-dialysis BPs, Outcomes (KDIGO) held a Controversies Conference, even if measured using a standardized protocol, are Blood Pressure and Volume Management in Dialysis,in imprecise estimates of interdialytic BPs15,16 and generally Lisbon, Portugal (https://kdigo.org/conferences/bp-volume- should not be used alone for diagnosing and managing management-in-dialysis/). The conference is the second of 4 hypertension. However, pre-, post- (i.e., peridialytic), and conferences planned on dialysis (see Chan et al.10 for the first intradialytic BP measurements do have clinical importance report, on dialysis initiation). Participants, who included both for assessing and managing hemodynamic stability during physicians and patients, considered how BP and volume the HD session. management can be optimized and individualized across Ambulatory BP monitoring is considered the gold- – dialysis modalities and resource settings. standard method for BP evaluation.17 19 Compared with peridialytic BP, 44-hour interdialytic BP has superior risk MAJOR THEMES prediction for all-cause and cardiovascular mortality.20,21 As participants addressed specific issues relating to BP and Ambulatory BP monitoring use may be limited by patient volume in dialysis, multiple crosscutting themes emerged. intolerance, availability, and financial constraints in some First was the substantial heterogeneity of the dialysis popu- countries.19 When ambulatory BP monitoring is unavailable, lation (e.g., incident vs. prevalent status, comorbid condi- home BP measurements may be taken twice a day, covering tions, residual kidney function [RKF], and nutritional status) interdialytic days over 1–2 weeks or twice a day for 4 days and the treatment setting (in-center vs. home therapies, following the midweek treatment.19,22 Compared with peri- medication use, etc.) that must be considered when pre- dialytic BP measurement in HD, home BP measurement has scribing dialysis. Second was the ever-present tension in superior agreement with mean 44-hour ambulatory BP balancing multiple, interlinked, volume-related factors within monitoring,23 higher short-term reproducibility,24 and a narrow therapeutic window for avoiding complications improved prediction of adverse outcomes.20,21 Key disad- (Figure 1). In some instances, correcting one volume-related vantages of home BP monitoring are the absence of infor- abnormality (e.g., hypervolemia) may result in increasing risk mation on nocturnal dipping, and in some settings, cost. associated with another volume-related parameter (e.g., ul- A third alternative is BP measurement in-office, not in the trafiltration [UF] rate and RKF). Data to guide these decisions dialysis unit. Increased systolic BPs (SBPs) outside of the are limited. Third was recognition of the impact that poorly dialysis unit are an independent risk factor for mortality.25 managed BP and volume have on patient lives, and the Another alternative is mean or median peridialytic BP (pre-, importance of incorporating patient priorities into manage- inter-, and post-HD BP values), which has greater sensitivity ment decisions. Fourth, availability of local resources and and specificity in detecting interdialytic hypertension than technologies vary globally and often dictate the bounds of pre- or post-dialysis BP measurements alone.26 However, no dialysis prescriptions. Therefore, individualizing the dialysis studies have assessed the association of this approach with prescription to manage BP and volume for each patient and outcomes. setting is essential and requires incorporating numerous Data assessing the validity of peridialytic, office, and home factors into decision-making. Finally, there was broad-based BP in patients receiving home HD or peritoneal dialysis
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