PD and Hypertension

Hi Dr. Agar,

I have been on PD now going on 3 months, I do 4 exchanges a day 2.5%, 15%, 2.5%, 1.5%. . It was my understanding that with PD, my blood pressure would start to stabilize. This has not been the case, it can run anywhere from 120/82 to 165/110 on any given day and time. I am Lopressor, Procardia, and Clonidine to try to control it, but so far, this has not been successful. My concern is that with continual hypertension, it cannot be good on my heart. Any suggestions as what I may discuss with my nephr. Oh, you may also need to know that I have sleep apnea. I do use my CPAP machine every night without fail.

I thank you in advance.

GUYNFTL68

Sorry, but I have been away on an Easter break and now have some ‘catching up’ to do. I will get to an answer shortly.

John Agar

Dear GUYNFTL68

Though strictly the site I offer answers for is an HD (not a PD) site and you may wish to ask the same question of our PD expert, I will give a short response to you as best I can.

However, I am afraid your question is one you may have to mainly discuss with your doctor rather than with either myself or Judy.

Why? …

Well, the causes of hypertension (high blood pressure) in chronic kidney disease (CKD) are so many and varied that it is impossible for me to know exactly what is ‘driving’ your continued high BP …

Is it that you are still fluid overloaded? … if so, the removal of more fluid by PD may be the best initial response: either by increasing the ‘strength’ of your bags - eg: to all 2.5% or by adding in an overnight bag of icodextrin (or, if you were an APD patient, a daytime dwell bag of icodextrin).

Or, perhaps your underlying disease process is either primarily one of renovascular disease (small or large vessel) or that renovascular disease is a complicating factor in, say, an underlying GN (glomerulonephritis) or primary diabetic nephropathy. Other renal diseases may also be factors.

It is not uncommon for hypertension to persist and require ongoing treatment even after dialysis begins … and the list of antihypertensive agents that you already taking suggests that hypertension has been a significant factor in the course of your disease. And thus it may continue to be - sadly - despite that you have begun dialysis.

The fact that you have sleep apnoea (and despite your (laudable) regular use of CPAP) raises the question of complicating weight issues. Overweight patients have a higher risk of high blood pressure in the first place or, if already hypertensive, have more difficult-to-control blood pressure. If a factor in your case - and I am being presumptious here - then your weight problems will not be helping to lessen your blood pressure. In addition, sleep apnoea itself is often accompanied/complicated by hypertension.

I have to ‘cop out’ here and say that I think that all this is for you and your doctor to sort out between you. I understand your natural frustration and your disappointment that your BP has not somehow magically disappeared with the starting of dialysis and that your pill list (and your hypertension) continue, seemingly unabated. Sadly, this is commonly the case.

While blood pressure can often be more agressively controlled by haemodialysis than by peritoneal dialysis, this does not mean that I am suggesting for a moment that you switch modalities - PD is a very good dialysis method for many patients (and for many more than actually seem to access it in the US) and BP control would not normally, of itself, be regarded as a reason to ‘jump ship’ to HD.

More fluid removal may help (as I suggested above) - but I would discuss if this is so with your team. At the end of the day, however, I am afraid that you may need to be prepared for an ongoing battle with the control of your blood pressure, despite having started dialysis. It may settle (or become easier to manage) with time but, sadly, dialysis does not cure and resolve all the battles of CKD.

Would that that were so.

John Agar
http://www.nocturnaldialysis.org