Hypertension and Blood Pressure Control in Hemodialysis Patients

Hypertension is one of the most prevalent and clinically significant comorbidities in patients with chronic kidney disease, particularly those undergoing hemodialysis. The interplay between renal dysfunction, fluid overload, vascular remodeling, and neurohormonal dysregulation renders blood pressure control a complex challenge in this high-risk population. Despite advances in dialysis techniques and pharmacological therapy, approximately 60–80% of HD patients continue to experience hypertension, which is strongly associated with left ventricular hypertrophy, accelerated cardiovascular morbidity, and premature mortality.This review synthesizes current evidence on the pathophysiology of hypertension in CKD and hemodialysis, highlighting the roles of the renin–angiotensin–aldosterone system, sympathetic overactivity, oxidative stress, and arterial stiffness. Epidemiological data on the global prevalence of hypertension in HD patients are discussed, alongside the clinical consequences of uncontrolled BP, including glomerular injury, residual kidney function decline, and cerebrovascular disease. Challenges to optimal BP control are outlined, with emphasis on intradialytic BP fluctuations, fluid overload, and medication–dialysis interactions.Management strategies are explored in depth, spanning fluid balance optimization, dialysis prescription modifications, lifestyle interventions, and pharmacotherapy with renin–angiotensin system inhibitors, calcium channel blockers, beta-blockers, and mineralocorticoid receptor antagonists. Finally, we examine the outcomes of effective BP control, including reductions in LVH, stroke incidence, and all-cause mortality, while emphasizing research gaps such as individualized BP targets, biomarker-guided therapy, and the role of novel agents.Given the profound impact of hypertension on survival and quality of life in HD patients, a multidisciplinary approach integrating nephrology, cardiology, and patient-centered care is essential.