What is the best next step in managing hypertension in a patient with ESRD and CKD stage 3 on hemodialysis, currently on atenolol, amlodipine, and clonidine, with elevated blood pressure?

From the Guidelines

The best next step in managing hypertension in this ESRD patient on hemodialysis with CKD stage 3 is to optimize the dialysis prescription by reassessing dry weight and potentially increasing ultrafiltration during dialysis sessions, as volume overload is the most common cause of resistant hypertension in hemodialysis patients. According to the 2020 international society of hypertension global hypertension practice guidelines 1, if seated office BP >140/90 mm Hg in patients managed with three or more antihypertensive medications at optimal (or maximally tolerated) doses including a diuretic, first exclude causes of pseudoresistance and consider screening patients for secondary causes.

The current regimen of atenolol, amlodipine, and clonidine is reasonable but may need dose adjustments; atenolol should be given post-dialysis as it is removed during treatment, as suggested by the resistant hypertension: detection, evaluation, and management: a scientific statement from the american heart association 1. Medication timing is crucial - administering antihypertensives after dialysis rather than before can improve efficacy.

Blood pressure targets for hemodialysis patients are less stringent than the general population, aiming for predialysis values <160/90 mmHg and postdialysis values <150/80 mmHg. Addressing volume status first is essential because pharmacological management alone often fails when excess fluid remains the primary driver of hypertension in ESRD patients. The executive summary of the kdigo 2024 clinical practice guideline for the evaluation and management of chronic kidney disease 1 also supports continuing ACEi or ARB in people with CKD even when the eGFR falls below 30 ml/min per 1.73 m2, which may be beneficial in this patient.

Some key points to consider in managing this patient's hypertension include:

• Optimizing dialysis prescription to address volume overload
• Adjusting medication timing to improve efficacy
• Monitoring potassium levels when using ACE inhibitors or ARBs
• Considering the use of long-acting ACE inhibitors or ARBs
• Aiming for less stringent blood pressure targets in hemodialysis patients.

Overall, the management of hypertension in this ESRD patient on hemodialysis with CKD stage 3 requires a multifaceted approach that addresses volume status, medication timing, and blood pressure targets, with careful consideration of the patient's individual needs and comorbidities, as outlined in the resistant hypertension: detection, evaluation, and management: a scientific statement from the american heart association 1 and the executive summary of the kdigo 2024 clinical practice guideline for the evaluation and management of chronic kidney disease 1.

From the FDA Drug Label

Atenolol is excreted by the kidneys; consequently dosage should be adjusted in cases of severe impairment of renal function Patients on hemodialysis should be given 25 mg or 50 mg after each dialysis; this should be done under hospital supervision as marked falls in blood pressure can occur. Although a similar dosage reduction may be considered for elderly and/or renally-impaired patients being treated for indications other than hypertension, data are not available for these patient populations The best next step in managing hypertension in a patient with ESRD and CKD stage 3 on hemodialysis, currently on atenolol, amlodipine, and clonidine, with elevated blood pressure, is to adjust the atenolol dosage considering the patient's renal impairment.

• The patient is already on hemodialysis, so the atenolol dose should be given after each dialysis, under hospital supervision, to avoid marked falls in blood pressure.
• Consideration should be given to reducing the dose of atenolol to 25 mg or 50 mg after each dialysis, as recommended for patients on hemodialysis 2.
• It is also important to monitor the patient's blood pressure closely and adjust the atenolol dose accordingly to avoid hypotension.
• Additionally, the patient's clonidine dose should be monitored, as sudden cessation of clonidine treatment can result in a rapid rise in blood pressure 3.

From the Research

Management of Hypertension in ESRD and CKD Stage 3

The patient's condition of elevated blood pressure despite being on atenolol, amlodipine, and clonidine, necessitates a reevaluation of the current treatment regimen. Considering the patient's history of ESRD and CKD stage 3 on hemodialysis, the following options can be explored:

• Mineralocorticoid Receptor Antagonists: Studies have shown that mineralocorticoid receptor antagonists, such as spironolactone or eplerenone, can provide effective antihypertensive treatment, especially in patients with resistant hypertension 4, 5. However, caution is advised in patients with advanced CKD due to the increased risk of hyperkalemia 6, 7.
• Combination Therapy: Combination therapy including a diuretic, a long-acting calcium channel blocker, an angiotensin-converting enzyme inhibitor, a beta blocker, and a mineralocorticoid receptor antagonist may be considered for patients with treatment-resistant hypertension 5.
• Monitoring and Adjustments: Close monitoring of serum potassium levels and adjustment of the treatment regimen as needed is crucial to prevent hyperkalemia, especially when using mineralocorticoid receptor antagonists 7.

Key Considerations

When managing hypertension in patients with ESRD and CKD stage 3, the following key points should be considered:

• The patient's renal function and the potential risk of hyperkalemia when using certain medications
• The importance of close monitoring of serum potassium levels and adjustment of the treatment regimen as needed
• The potential benefits of combination therapy in achieving blood pressure control
• The need for individualized treatment approaches based on the patient's specific condition and medical history

Potential Next Steps

Based on the patient's current condition and medical history, potential next steps could include:

• Adding a mineralocorticoid receptor antagonist, such as spironolactone or eplerenone, to the current treatment regimen, while closely monitoring serum potassium levels 4, 5
• Adjusting the current treatment regimen to optimize blood pressure control and minimize the risk of hyperkalemia 7
• Considering alternative treatment options, such as baroreflex activation or renal denervation, for patients with treatment-resistant hypertension 5