Education Use Only
For educational use only — The physician’s written order and the unit protocol always govern
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Dialysis Nursing Reference Card  ·  Maintenance Hemodialysis

N6 — Blood Pressure at the Chair

Home BP guides chronic treatment. Dialysis-unit BP tells you whether today's treatment is safe.
Andrew Bland, MD, FACP, FAAP Reviewed September 2026 · v1.0 draft Prints on one sheet, front and back
N6 — Blood Pressure at the Chair FRONT
Front · at the chair

When: any high or low reading before, during, or after treatment.

Do this

  1. Measure it right: seated, rested, correct cuff, non-access arm. Repeat a high reading after a few minutes’ rest before acting on it.
  2. Record the lowest systolic BP (SBP) every treatment. SBP below 90 — or below 100 if pre-dialysis SBP was 160 or higher — gets the hypotension response even if the patient feels fine; so do symptoms at any number (N5: Intradialytic Hypotension: Chair-Side Response) [3,5].
  3. Isolated high pre-dialysis reading, no symptoms: recheck after rest, document, trend. No extra antihypertensive and no extra UF on the strength of that reading [1].
  4. Track the pattern: an SBP rise of more than 10 mmHg from pre- to post-dialysis into the hypertensive range in 4 of 6 consecutive treatments is a flag for review [5].
  5. Home BP log: validated upper-arm device, two readings morning and evening for about a week, including non-dialysis days. A home average of 135/85 or higher is hypertension [6].
  6. BP medicines on dialysis days: take them as prescribed unless the nephrologist has ordered a specific drug held or moved to the evening [4,7].

Call the nephrologist when

  • Severe hypertension with chest pain, shortness of breath, new neurologic deficit, confusion, severe headache, or visual change — an emergency per unit protocol. Symptoms matter more than the number.
  • Hypotension that does not recover, or comes with chest pain, arrhythmia, or confusion.
  • Nadir SBP below 90 in 30% or more of treatments over the past month [3,5].
  • The target weight cannot be reached without a UF rate above 13 mL/kg/h (N4: UF Rate and Treatment Time).
  • The intradialytic hypertension pattern (4 of 6 treatments), or pre-dialysis BP of 180/110 or higher on two consecutive treatments — the level DRIP used to trigger ambulatory monitoring [8].
  • Home average 135/85 or higher, or new low home readings with dizziness or falls [6].

Don’t

  • Don’t give a PRN antihypertensive for an asymptomatic high chair-side reading.
  • Don’t lower the target weight or raise UF because of one high pre-dialysis BP.
  • Don’t tell patients to hold BP medicines before dialysis unless ordered for that patient [4].
N6 — Blood Pressure at the Chair BACK
Back · why, and the evidence

Why

  1. Pre- and post-dialysis SBP did not predict death once home and ambulatory BP were measured (P = 0.17 and 0.997); home and ambulatory SBP did [1].
  2. One week of home readings identified true hypertension better than two weeks of pre-dialysis readings (AUC 0.934 vs 0.778) [2].
  3. A nadir SBP below 90 in 30% or more of treatments carried higher mortality (adjusted HR 1.22–1.38); requiring symptoms did not improve the signal [3].
  4. In the one randomized test, taking BP medicines before dialysis could not be shown as good as holding them for asymptomatic hypotension (8% more; 95% CI −3% to 19%), but uncontrolled pre-dialysis hypertension was less frequent (difference 15%) [4]. UK guidance advises against routine omission [7].

Go deeper

References

  1. Agarwal R. Blood pressure and mortality among hemodialysis patients. Hypertension. 2010;55:762-768. PubMed 20083728
  2. Leonidou K, et al. Home versus routine dialysis-unit blood pressure recordings among patients on hemodialysis. J Hum Hypertens. 2025;39:355-361. PubMed 40097627
  3. Flythe JE, et al. Association of mortality risk with various definitions of intradialytic hypotension. J Am Soc Nephrol. 2015;26:724-734. PubMed 25270068
  4. Chang TI, et al. Timing of antihypertensive medications on key outcomes in hemodialysis (TAKE-HOLD). Kidney360. 2021;2:1752-1760. PubMed 35373003
  5. Flythe JE, et al. Blood pressure and volume management in dialysis: conclusions from a KDIGO Controversies Conference. Kidney Int. 2020;97:861-876. PubMed 32278617
  6. Sarafidis PA, et al. Hypertension in dialysis patients: a consensus document by EURECA-m and the ESH Hypertension and the Kidney working group. Nephrol Dial Transplant. 2017;32:620-640. PubMed 28340239
  7. Doulton T, et al. Management of blood pressure in adults, children and young people on dialysis: UK Kidney Association guideline. BMC Nephrol. 2025;26:532. PubMed 41013409
  8. Agarwal R, et al. Dry-weight reduction in hypertensive hemodialysis patients (DRIP). Hypertension. 2009;53:500-507. PubMed 19153263

Reviewed by Andrew Bland, MD, FACP, FAAP · v1.0 draft 2026-09-26. For education; the physician’s written order and the unit protocol always govern.