INTRODUCTION
Hypertension is one of the most prevalent modifiable cardiovascular risk factors in patients with end-stage kidney disease (ESKD). It affects approximately 80–90% of patients undergoing peritoneal dialysis (PD) and hemodialysis (HD) [1-3]. Poor BP control in dialysis patients is strongly associated with left ventricular hypertrophy, cardiovascular events, and increased mortality.
Given that cardiovascular disease remains the leading cause of death in patients with ESKD, effective BP management is essential for improving clinical outcomes [4, 5].
Dialysis plays a crucial role in BP regulation by removing excess fluid and sodium, which are key contributors to hypertension in CKD. HD relies on intermittent ultrafiltration (UF) performed two to three times per week, often leading to BP fluctuations and interdialytic weight gain [6, 7]. In contrast, PD offers continuous UF, potentially providing more stable BP control [6, 8].
Several studies have suggested that PD patients tend to have better BP regulation due to superior volume control, sodium removal, and the preservation of residual kidney function [6-9]. However, conflicting evidence exists, and not all studies demonstrate a clear advantage of PD over HD in BP control. Concerns such as UF failure, peritoneal membrane dysfunction, and inflammation can contribute to resistant hypertension [10, 11].
Studies also have found that, in particular, patients with high peritoneal transport status, the current practice of CAPD is deemed unsuitable and may cause further comorbidities, such as fluid retention, malnutrition, and atherosclerosis [12,13].
Therefore, this review aims to critically evaluate and compare the impact of HD and PD on BP regulation, exploring the underlying mechanisms, clinical implications, and potential advantages of each modality. By analyzing current evidence, this paper seeks to provide insights that may guide clinicians in selecting the most appropriate dialysis modality for patients who are struggling with hypertension.
HYPERTENSION IN CHRONIC KIDNEY DISEASE
Hypertension is a leading cause of global disease burden and a public health threat due to its potential to cause various complications, such as stroke, coronary heart disease, and kidney failure [14,15]. Hypertension is one of the main risk factors for CKD, but CKD can also be both a common cause and consequence of inadequately treated hypertension [15,16]. Previous studies have shown a significant association between hypertension and CKD, indicating that individuals with hypertension have a 4.1 times higher risk of developing CKD compared to those without hypertension [17].
In Indonesia alone, the prevalence of hypertension in individuals aged 18 and above was recorded at 7.2% in 2007, increasing to 9.4% in 2013, and slightly decreasing to 8.36% in 2018 [18–20]. Interestingly, this trend correlates with findings from Ramadhanti et al., who identified hypertension as a strong independent risk factor for CKD (OR = 3.14; 95% CI: 1.527–6.453; p = 0.002), alongside age, diabetes, heart disease, and low physical activity [16].
According to the latest 2024 guidelines from the European Society of Cardiology (ESC), hypertension is defined as office systolic blood pressure (SBP) ≥140 mmHg or diastolic blood pressure (DBP) ≥90 mmHg. To confirm a hypertension diagnosis, it is recommended that BP measurements also be taken outside the office (using Home Blood Pressure Monitoring (HBPM) or Ambulatory Blood Pressure Monitoring (ABPM)) or at least verified through repeat measurements on subsequent visits. A new category called “elevated blood pressure” has been established for SBP of 120-139 mmHg or DBP of 70-89 mmHg [21].
ABPM is currently recommended for use in diagnosing and making treatment decisions for all patients with ESKD, as it offers several advantages, including superior prognostic value [4].
BP Measurement in CKD
Accurate BP measurement is crucial for effective hypertension management. In practice, hypertension treatment is often based on BP measurements taken in clinics or healthcare facilities [22], which can be less accurate due to the absence of repeat measurements, daily BP variations, and white coat hypertension [23]. Ambulatory Blood Pressure Monitoring (ABPM) over 24 hours provides a more precise representation of BP phenotypes and is more effective in predicting cardiovascular events in CKD patients compared to clinic-based measurements [24].
Additionally, 24-hour ABPM allows for monitoring BP fluctuations throughout the day. Home BP monitoring is a more economical alternative but should ideally be used for patients with better BP control [25]. Current hypertension guidelines, including the 2017 American College of Cardiology (ACC) guidelines (Fig.
1), recommend out-of-office BP measurements to confirm a hypertension diagnosis and adjust antihypertensive medication doses [26]. For accuracy, only calibrated home BP devices should be used [27]. The ACC guidelines also indicate that clinic BP of 140/90 mmHg roughly corresponds to home BP of 135/85 mmHg and ABPM readings of 135/85 mmHg during the day and 120/70 mmHg at night [26].
Hypertension in CKD Patients Undergoing Hemodialysis
Hypertension is a leading cause of CKD and remains a serious issue that must be addressed even after patients undergo renal replacement therapy, such as HD or PD [4]. Increased blood pressure is directly associated with lower survival rates and higher cardiovascular events. Hypertension, defined as blood pressure above 140/90 mmHg, is commonly experienced by patients undergoing regular HD, with a prevalence ranging from 50% to 60% [29].
The pathophysiology of hypertension in HD patients is complex and arises from various factors distinct from those affecting the general population (Fig. 2). Causes of hypertension in HD include:
Hypertension in CKD Patients Undergoing Peritoneal Dialysis
Hypertension is a common health issue faced by patients undergoing PD for the treatment of ESKD. One of the primary causes of hypertension in these patients is fluid overload, often associated with the decline in residual kidney function [48]. In ESKD patients, the kidneys’ ability to excrete fluid is limited, leading to fluid accumulation in the body.
Although PD is generally more effective in controlling fluid volume compared to hemodialysis, many patients still struggle with blood pressure management, particularly when their ideal dry weight is not maintained [48–50]. The pathophysiology of hypertension in PD patients (Fig. 3) can be explained as follows:
The volume control is better in patients with PD who undergo daily dialysis procedures compared to HD patients. However, because PD patients visit healthcare facilities less frequently than HD patients, achieving the target post-dialysis weight is easier for HD patients [54-56]. Additionally, patients with hypertension and volume overload are at high risk of cardiovascular problems, such as left ventricular hypertrophy, which can lead to cardiovascular death [57].
Overall, the mechanisms underlying hypertension in PD patients, such as volume overload from suboptimal UF, diminished residual kidney function, and high peritoneal transport rates, are consistent with the findings of this review. Several studies highlighted in our analysis reported that PD patients with impaired UF or reduced RKF were more likely to have uncontrolled blood pressure. These pathophysiological insights support the notion that volume status remains a dominant factor in PD-related hypertension.
Moreover, the impact of peritoneal membrane transport type reinforces this link, as high transporters often require more intensive fluid management strategies. Therefore, by aligning the observed clinical trends with these mechanistic pathways, continuous attention and proper management approaches are necessary to improve the health and quality of life of patients with ESKD.
COMPARISON OF HYPERTENSION IN HEMODIALYSIS AND PERITONEAL DIALYSIS PATIENTS
Hypertension in dialysis patients is multifactorial, yet significant differences exist in the mechanisms, clinical manifestations, and management outcomes between those receiving HD and PD. In HD, blood pressure fluctuations are often influenced by large interdialytic weight gains and rapid UF during treatment sessions. These abrupt volume shifts can activate the sympathetic nervous system and disrupt endothelial function, leading to greater blood pressure variability and long-term cardiovascular complications.
Volume overload, therefore, remains a dominant and recurring issue in HD-related hypertension, despite efforts to optimize dry weight and UF rates [30-32].
In contrast, PD allows for more continuous and gradual fluid removal, which is generally associated with more stable hemodynamics and less blood-pressure variability. Several studies suggest that PD patients may achieve better long-term blood-pressure control due to this steady-state approach [54-58]. Moreover, PD avoids the cyclic volume depletion, repletion seen in HD, contributing to reduced sympathetic activation and improved cardiovascular stability [59, 60].
However, the advantage of PD is not universal. Factors such as high peritoneal membrane transport status, diminished RKF, and suboptimal sodium removal can compromise volume control in PD patients, resulting in hypertension similar to that observed in HD [12, 13, 48, 49].
Although PD may offer advantages in terms of continuous volume control and hemodynamic stability, individual patient characteristics ultimately determine the effectiveness of blood-pressure (BP) management. Patients on dialysis are highly heterogeneous in terms of membrane transport status, dietary habits, residual renal function, and existing comorbidities such as diabetes mellitus and cardiovascular disease. These factors significantly influence volume management, UF efficiency, and therefore hypertension outcomes [12, 61, 62].
Preserving RKF has been consistently associated with better blood-pressure control in both PD and HD, owing to ongoing fluid and sodium excretion [63]. Considering this complexity, dialysis prescriptions must be tailored not only to modality but also to patient-specific risk profiles.
This review, however, is limited by the heterogeneity of included studies, differences in blood-pressure measurement techniques (office vs. ABPM), and the scarcity of randomized controlled trials directly comparing HD and PD for blood-pressure outcomes. Additionally, most of the cited journal articles are observational and cross-sectional studies, which may be subject to confounding and bias.
CONCLUSION
Hypertension in chronic kidney disease patients is a complex issue that requires special management. High blood pressure can worsen kidney function, and conversely, kidney damage can trigger hypertension. PD offers several advantages in blood-pressure control compared to HD.
The continuous UF process in PD allows for gradual and more stable fluid removal, helping to reduce the heart's workload and lower blood pressure (BP). Furthermore, PD is more effective in removing excess sodium, one of the main causes of hypertension. Thus, PD not only helps control blood pressure but also improves fluid and electrolyte balance in the body, and its effectiveness is highly dependent on patient adherence to therapy and proper management of fluid and sodium intake.
While PD has demonstrated potential advantages in blood pressure control, these benefits can be offset by intrinsic patient factors and peritoneal transport limitations. Future research should prioritize prospective, head-to-head studies with standardized BP metrics to more accurately delineate the comparative efficacy of HD and PD in hypertension management. Stratifying patients by RKF, transport type, and volume status may offer insights to guide more individualized and effective dialysis care.