What is the preferred antihypertensive (high blood pressure) medication in a patient with End-Stage Renal Disease (ESRD) on Hemodialysis (HD), already taking nifedipine, with uncontrolled Hypertension (HTN) and a history of Hyperkalemia (elevated potassium levels) with losartan?

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

The preferred antihypertensive medication for a patient with ESRD on hemodialysis who is already taking nifedipine, has uncontrolled hypertension, and has a history of hyperkalemia with losartan would be a beta-blocker such as metoprolol or a central alpha-2 agonist like clonidine. Specifically, metoprolol tartrate starting at 25-50 mg twice daily (or metoprolol succinate 50-100 mg once daily) would be appropriate, with dose adjustments based on blood pressure response and heart rate 1. For this patient, ACE inhibitors and ARBs (like losartan) should be avoided due to the history of hyperkalemia, as these medications can further elevate potassium levels 2, 3. Beta-blockers are particularly beneficial in ESRD patients as they have minimal renal clearance, help control the sympathetic overactivity common in these patients, and don't significantly affect potassium levels 2, 1. Additionally, they complement the calcium channel blocker (nifedipine) already prescribed by working through a different mechanism. Some key points to consider when managing hypertension in ESRD patients include:

• Control of extracellular volume with ultrafiltration and dietary sodium restriction represents the principal strategy to manage hypertension in ESRD 1
• Antihypertensive medications are subsequently added if this strategy is inadequate 1
• Beta-blockers decrease not only mortality, blood pressure (BP), and ventricular arrhythmias, but also improve left ventricular function in ESRD patients 2
• The use of calcium channel blockers is also associated with lower total and cardiovascular-specific mortality in HD patients 2 Blood pressure should be monitored closely, particularly during dialysis sessions, and the medication schedule may need to be adjusted around dialysis treatments to maintain consistent blood pressure control 4. It's also important to note that intensive HD reduces BP and the need for antihypertensive medications 4, which could be a consideration in the overall management plan for this patient.