Blood Pressure Beyond the Dialysis Chair

As a kidney patient who has been undergoing hemodialysis for a period of over 30 years, I can say that BP becomes more than just a number, it becomes a story about how my own body responds to removal of fluid, nutrition, stress, restrictions, and medication. Bansal's work “Nephrologists’ Perceptions of Management of Hypertension in Hemodialysis Patients” discusses an important and sometimes silent lens about BP and how nephrologists view the role of home BP monitoring concerning more informed decision making for dialysis patients. For so many of us on dialysis, BP control in clinic can really reveal the feeling we are far away from how we live each day. Sitting in the dialysis chair, being connected to the machine far from your home and normal day to day environment. This study findings are a recognition of patients’ home BP readings as a more normal and truly representative measure. The study findings point to an evolution of recognizing that the lives of patients, their health, and wellbeing are much more than the dialysis chair inside hospital walls. This qualitative study provides real-world data on home BP monitoring, as it is still limited in dialysis centers. The methods, semistructured interviews, provide rich detail on participants’ perceived benefits, risks, and barriers to home BP monitoring.1 I love how clinicians acknowledged that home BP monitoring may empower patients to have a perceived level of control over their own care. This is often how we feel when we are given the tools for self-management of aspects of our care, whether it is our BP, understanding our dry weight, or managing our medications. When we feel like our clinicians trust and are collaborating with us for our active participation, that fosters the partnership that is so vital to the self-management of chronic disease. The key to empower people is not only information but is also education promoting self-caring.2 The study also highlights another positive topic, how clinicians recognize the limitations of dialysis units BP monitoring. My consideration is to reflect a critical question, why we are still using scales to check dry weights in the 21st century at hemodialysis units? I am sure this is not the best method for volume control and removal of fluid with the goal of BP control. The potential for home readings to improve cardiovascular outcomes offers a light in the darkness of interdialytic sessions. Only us as patients, we know the truth of 48 hours/72 hours between dialysis sessions about fluids, electrolytes, and weight gain for an effective control of BP. Salt and uremic toxins are our enemy as hemodialysis patients,3 not only for BP control but also for thirst and to avoid weight gain at home. Nephrologists are now aware about these gaps and the need for evidence and data, as part of how to implement change. It is important to understand the perspectives of nephrologists; however, to understand practice in the real world, we also need to understand how patients view home BP monitoring, the challenges, confidence in using the devices, and how this affects our sense of safety and participation in our health care team? The clinicians in the study also express concerns about the patient's ability to use home monitors, such as cuff size, posture, timing, and so forth. Although these are legitimate concerns, these are all indications that we need to better educate our patients and to have a health systems approach. In fact, if patients were engaged in writing and codesigning these educational materials or protocols,4 they could help bridge the gaps in clinical outcomes and quality of life for patients. BP management is a partnership, especially regarding accuracy. In home BP monitoring, it is a valuable experience to the patient, not just an exercise in technical abilities. It is a form of self-control, involvement, and engagement in the management of their own health care. Patients learn how lifestyle, fluid intake, diet, and emotions can change BP. When clinicians validate these data and consider it with value, they develop trust and shared accountability. We need to link both clinical outcomes with patient daily lives. Nevertheless, home monitoring should not create additional burden.5 Patients face tough routines and if we ask them to conduct additional tasks without support, frustration, and nonadherence may arise. If we can streamline the process, whether through digital options, educational sessions, or dedicated nursing, we can convert home BP measurement and monitoring from a burden into part of integrated care. Bansal and colleagues are shaping the way nephrologists' approach and patients engage with home BP management. It is a step toward more individualized, personalized, and patient-centered care. As a patient, I take this as an invitation to go from being a patient that has only known BP values during their dialysis sessions, to a person that knows, understands and can share their understanding, at home in partnership, to improve survival and quality of life. The future of dialysis care should not be constrained to where and how we are measuring BP, but how we work with patients to help them understand the concept of co-responsibility, self-caring, and being part of the health care team as an equal partner with their clinicians, although the team is at home or in a dialysis care unit.