What are safe antihypertensive medications for patients with Impaired Renal Function undergoing dialysis?

From the Guidelines

For dialysis patients, ACE inhibitors and ARBs are generally considered safe and effective blood pressure medications, as they protect kidney function and reduce cardiovascular risk, with lisinopril (ACE inhibitor) at 2.5-40 mg daily or losartan (ARB) at 25-100 mg daily being commonly prescribed options 1. These medications are preferred because they work by blocking the renin-angiotensin-aldosterone system, which helps control blood pressure without putting additional stress on the kidneys. When prescribing, start at a low dose and titrate up slowly while monitoring blood pressure and potassium levels. Dosing may need to be adjusted based on the patient's residual kidney function and dialysis schedule. Some key points to consider when managing hypertension in dialysis patients include:

• Avoiding diuretics in most dialysis patients, as they typically have minimal urine output 1
• Using beta-blockers like metoprolol as add-on therapy if needed, but requiring careful dosing due to altered drug clearance in kidney failure
• Consulting with the patient's nephrologist before making changes to blood pressure medications, as individual factors may influence the choice and dosing of antihypertensive drugs in dialysis patients It's also important to note that the use of ACE inhibitors has been associated with decreased mortality in cohorts of CKD Stage 5 patients 1. Overall, the goal is to control blood pressure while minimizing the risk of adverse effects and preserving kidney function, with the most recent guidelines supporting the use of ACE inhibitors and ARBs as first-line therapy 1.

From the FDA Drug Label

Impaired renal function decreases elimination of lisinopril, which is excreted principally through the kidneys, but this decrease becomes clinically important only when the glomerular filtration rate is below 30 mL/min. Lisinopril can be removed by hemodialysis. Dose adjustment of lisinopril is required in patients undergoing hemodialysis or whose creatinine clearance is ≤ 30 mL/min.

Safe antihypertensive medications for patients with impaired renal function undergoing dialysis are not explicitly stated in the provided drug labels. However, based on the information provided, lisinopril can be used in patients with impaired renal function, but dose adjustment is required in patients undergoing hemodialysis or with a creatinine clearance ≤ 30 mL/min 2, 2, 2.

• Key considerations for using lisinopril in patients with impaired renal function include:
  • Monitoring renal function periodically
  • Risk of hyperkalemia, especially in patients with renal insufficiency
  • Potential for anaphylactoid reactions during dialysis
• Lisinopril can be removed by hemodialysis, which may be an important consideration in patients undergoing dialysis.

From the Research

Safe Antihypertensive Medications for Patients with Impaired Renal Function Undergoing Dialysis

• Angiotensin converting enzyme inhibitors (ACE inhibitors) and angiotensin receptor blockers (ARBs) are considered safe and effective for patients with impaired renal function undergoing dialysis, due to their safety profile and demonstrated benefit on cardiovascular outcomes in clinical trials 3, 4, 5.
• Beta-blockers and combined alpha- and beta-blockers can also be used in patients with cardiovascular disease or congestive heart failure, and may improve outcomes in these populations 3, 5.
• Calcium channel blockers and direct vasodilators are also effective for controlling blood pressure in patients with impaired renal function undergoing dialysis 3.
• Lisinopril, an ACE inhibitor, has been shown to be effective and safe in patients with end-stage renal failure, and can be dosed once daily or thrice weekly following hemodialysis 6, 7.
• Medications that are removed with dialysis, such as lisinopril and atenolol, can be preferred in patients who are prone to develop intradialytic hypotension, and can be given thrice weekly following hemodialysis 3, 5.

Considerations for Medication Selection

• Patient comorbidities must be considered when selecting antihypertensive medications for patients with impaired renal function undergoing dialysis 5.
• The removal of medications with dialysis must be considered upon medication selection, as there may be large variability in drug removal with dialysis within a class of antihypertensive medications 5.
• Thrice-weekly dosing of medication after dialysis may be a useful regimen in nonadherent patients, as studies demonstrate that it has robust blood pressure-lowering effects 5.