What are the recommended medications for managing blood pressure in patients with End-Stage Renal Disease (ESRD)?

Blood Pressure Management in End-Stage Renal Disease (ESRD)

Renin-angiotensin system inhibitors (ACEi or ARB) should be the first-line antihypertensive agents for ESRD patients, especially those with albuminuria, due to their proven benefits in reducing mortality and cardiovascular events beyond blood pressure control. 1, 2

First-Line Medications

Renin-Angiotensin System Inhibitors

• ACE inhibitors or ARBs are preferred first-line agents for ESRD patients with hypertension due to:
  • 52% reduction in mortality risk in hemodialysis patients 2
  • Cardioprotective effects independent of BP reduction 3
  • Reduction in the risk of progression to ESRD by 29% 4
  • Reduction in proteinuria by an average of 34% 4

Special Considerations for ESRD

• ARBs may be preferred over ACEi in ESRD patients because:
  • ARBs are not dialyzable, while many ACEi undergo substantial cross-dialyzer clearance 5
  • ARBs have fewer adverse effects like cough and anaphylactoid dialyzer reactions 5
  • ARBs have shown significant reduction in new-onset atrial fibrillation in ESRD patients 6

Second-Line and Add-On Medications

Dihydropyridine Calcium Channel Blockers (CCBs)

• Recommended as effective add-on therapy when BP targets are not achieved with RASi alone 1
• Particularly useful in kidney transplant recipients as first-line agents 7

Diuretics

• Loop diuretics are preferred for ESRD patients with volume overload 1
• Essential for volume control in conjunction with ultrafiltration 3

Mineralocorticoid Receptor Antagonists (MRAs)

• Effective for resistant hypertension in ESRD 1
• Require careful monitoring for hyperkalemia, especially in advanced CKD 7, 1
• Finerenone has shown kidney and cardiovascular protection in diabetic CKD 7, 1

Blood Pressure Targets

• Target systolic blood pressure of <120 mmHg when tolerated, using standardized office BP measurement 7
• This target is supported by evidence showing reduction in cardiovascular events and mortality 1

Monitoring and Follow-up

1. Check serum creatinine and potassium within 2-4 weeks of initiation or dose increase of RASi 7
2. Continue RASi therapy unless serum creatinine rises by more than 30% or uncontrolled hyperkalemia develops 7
3. Consider reducing dose or discontinuing RASi in cases of:
   • Symptomatic hypotension
   • Uncontrolled hyperkalemia despite medical treatment
   • Advanced kidney failure (eGFR <15 ml/min/1.73m²) 7

Important Cautions

1. Avoid combination therapy with ACEi, ARB, and direct renin inhibitors 7, 8
2. Hyperkalemia management:
   • Implement measures to reduce serum potassium rather than immediately reducing RASi dose 7
   • Monitor potassium levels closely, especially with MRAs 7
3. Medication timing:
   • For dialyzable medications, consider post-dialysis administration 3
   • Even thrice-weekly dosing after dialysis can have robust BP-lowering effects in non-adherent patients 3

Non-Pharmacological Approaches

• Sodium restriction to <2g sodium per day 1
• Volume control with ultrafiltration and dietary sodium restriction is the principal strategy before adding medications 3
• Physical activity of at least 150 minutes per week of moderate-intensity exercise when tolerated 1

By following this evidence-based approach to blood pressure management in ESRD, you can help reduce cardiovascular morbidity and mortality in this high-risk population.