Hypertension in Patients With End-Stage Kidney Disease Requiring Dialysis: Bridging the Divide Between Evidence and Practice

Hypertension is a highly prevalent and modifiable risk factor, affecting >80% of patients undergoing dialysis. Its pathophysiology is complex and differs from that of the general population, driven by factors such as volume overload, arterial stiffness, overactivation of the sympathetic and renin-angiotensin-aldosterone systems, and endothelial dysfunction. Achieving optimal blood pressure and volume control is central to dialysis care, with significant implications for cardiovascular outcomes and patient quality of life. Despite its importance, evidence guiding hypertension management in this population remains limited. Furthermore, reliable, objective methods to assess extracellular volume are lacking. This review examines current approaches to the assessment and management of hypertension in maintenance hemodialysis, summarizing existing evidence, clinical guidelines, and ongoing challenges in blood pressure and volume control.