Blood Pressure in Dialysis Patients (BID)

Inclusion Criteria

1. Age ≥ 18 years
2. On thrice weekly maintenance hemodialysis for greater than 90 days
3. Two-week average pre-dialysis RDUSYS BPM >=155 mm Hg or if less than 155 on antihypertensive medications as follows: at least 1 med for RDUSYS BPM 150-154, 2 meds for RDUSYS BPM 145-149; 3 meds for RDUSYS BPM 140-144. Patient and physician must agree to backtitrate medications if RDU SYS BPM <155.

Exclusion Criteria:

1. Two- week average, pre-dialysis mid-week SDUSBPM ≥180 mmHg on maximal doses of ≥ 4 antihypertensive agents;
2. Inability to measure blood pressures in an upper arm;
3. History of inter or post-dialytic hypotension (defined as systolic blood pressure <90 mmHg) within the past 2 weeks or inter- or post- dialytic hypotension requiring hospitalization (including emergency room visit) and/or the use of midodrine in the past 6 months;
4. Required one or more urgent, unscheduled dialysis treatment for congestive heart failure in the past 3 months (other than in an incident patient at the time of starting dialysis);
5. Acute myocardial infarction, unstable angina or stroke/ TIA in past three the 3 months;
6. Severe aortic valve stenosis (valve area <1cm 2) carotid artery stenosis (>70% stenosis);
7. Known abdominal aortic aneurysm >5 cm in diameter or thoracic aortic aneurysm of any diameter;
8. Body mass index >40 kg/m2 or arm circumference > 52 cm, which precludes measuring blood pressure with the "thigh" blood pressure cuff;
9. Life expectancy <1 year;
10. A living donor, kidney transplant, or switch to peritoneal dialysis scheduled within the next year;
11. Significant cognitive impairment;
12. spKt/V ≤1.2 in the past 2 months;
13. Active liver disease;
14. Active alcohol or substance abuse including narcotics within the past year;
15. Contraindication to cardiac MRI;
16. Current or planned pregnancy within the next year;
17. Unwillingness to consent to pregnancy test and/or use of birth control if of childbearing potential;
18. Suspicion that the participant will not be willing or able to adhere to prescribed medications and study protocol;
19. Incarcerated;
20. Significant concern about the study expressed by spouse, significant other, family member primary nephrologist or primary care physician;
21. Participation in another intervention study;
22. Unable to speak or understand English or Spanish;
23. Plan to relocate within one year;
24. participation in another intervention study .

During the screening pre-randomization phase, eligibility of potential subjects will be documented and evaluated using information in the On-Line Randomization Screen. Patients will be instructed in study design, objectives, and procedures, after which informed consent will be obtained. The study coordinator and site investigator should review this pre-randomization data with attention to judging the patient's ability to adhere to study protocols. A maximum of 12-weeks will be allowed between the screening visit and randomization. If over 12-weeks have elapsed, then potential subjects will need to be re-screened. Eligible participants will be instructed to bring their medications to the baseline visit.

The site PI and/or study coordinator will rescreen patients who appear to meet the study entry criteria using the Blood Pressure in Hemodialysis Pilot Study Eligibility Checking Form. The Blood Pressure in Hemodialysis Pilot Study Screening Physical Exam and Study Questionnaire Form will be completed for potential subjects who provide informed consent to assess eligibility for the study. For women of childbearing potential, a urine pregnancy test will be done at a local lab and the results documented on this form.