CARDIOVASCULAR AND SURVIVAL PARADOXES IN DIALYSIS PATIENTS: The Association between Blood Pressure and Mortality in ESRD—Not Different from the General Population?

Hypertension (HTN) is a traditional cardiovascular risk factor and is prevalent in end‐stage renal disease (ESRD). There are no adequately powered prospective studies that explore the natural history and outcomes of HTN and blood pressure management in ESRD. Observational studies have not uniformly showed a relationship between HTN and mortality risk in this population. Furthermore, many studies paradoxically show an increased risk of death associated with low and “normal” blood pressure (BP), sometimes referred to as “reverse epidemiology.” We review findings from observational studies specifically performed in ESRD and provide an alternative interpretation—that patients with kidney disease on dialysis therapy are indeed different from the general population. At minimum, these differences may be based on the prevalence of cardiovascular morbidity, specifically the excessive prevalence of congestive heart failure. However, there are other reasons for ESRD patients, especially those on hemodialysis, to exhibit differential effects with regard to blood pressure and outcomes. We explore the implications of available observational evidence and recommend studies that elucidate the differences between ESRD and the general population. Because of the higher mortality risk associated with low or “normal” BP, diagnostic and therapeutic options and strategies for ESRD patients whose BP falls within “goal” should be addressed in future iterations of clinical practice guidelines. These strategies may include assessment of cardiac function and careful attention to achieving optimal fluid balance.