What are safe hypertension medications for patients with End-Stage Renal Disease (ESRD)?

Safe Hypertension Medications for ESRD Patients

For patients with End-Stage Renal Disease (ESRD), ACE inhibitors, ARBs, calcium channel blockers (particularly amlodipine), and beta-blockers are the safest and most effective antihypertensive medications, with hydralazine as an additional option when blood pressure remains uncontrolled.

First-Line Medications

ACE Inhibitors and ARBs

• Recommended as first-line therapy despite ESRD 1, 2
• Benefits:
  • Cardioprotective effects independent of BP reduction 2
  • Reduce mortality and morbidity 1
  • May reduce C-reactive protein and oxidant stress 3
• Considerations:
  • Monitor for hyperkalemia
  • Avoid in patients with history of angioedema
  • Some agents (like lisinopril) have prolonged half-life in ESRD, allowing for thrice-weekly dosing after dialysis 3

Beta-Blockers

• Recommended as second-line therapy 1
• Benefits:
  • Decrease mortality and blood pressure 3
  • Improve left ventricular function 3
  • Reduce ventricular arrhythmias 3
• Considerations:
  • Non-selective beta-blockers may increase serum potassium
  • Atenolol has renal excretion and prolonged half-life in ESRD patients 3

Additional Options

Calcium Channel Blockers

• Amlodipine is specifically recommended when hypertension persists despite ACE inhibitors/ARBs, beta-blockers, and diuretics 1
• Benefits:
  • Associated with lower total and cardiovascular mortality in hemodialysis patients 3
  • Well-tolerated in ESRD with minimal accumulation 4
  • Does not require significant dose adjustment in renal impairment 5
• Dosing: Initial 2.5-5 mg daily, maximum 10 mg daily 6, 5

Hydralazine

• Recommended when hypertension persists despite first-line therapies 1
• Benefits:
  • Effective vasodilator for resistant hypertension 3
• Cautions:
  • May cause reflex tachycardia
  • Monitor for lupus-like syndrome with prolonged use 7

Treatment Algorithm for ESRD Hypertension

1. Step 1: Start with volume control through ultrafiltration and sodium restriction 2, 8

2. Step 2: If BP remains elevated, add one or more of:

   • ACE inhibitor (e.g., lisinopril)
   • ARB (e.g., valsartan)
   • Beta-blocker (e.g., atenolol)

3. Step 3: If BP remains uncontrolled, add:

   • Amlodipine (starting at 2.5-5 mg daily) 1, 5

4. Step 4: For resistant hypertension, add:

   • Hydralazine 1

Important Monitoring Considerations

• Check serum potassium regularly, especially with ACE inhibitors and ARBs 1
• Monitor for intradialytic hypotension, which may require medication adjustments
• Consider timing of medications in relation to dialysis sessions:
  • Some medications (lisinopril, atenolol) can be given thrice-weekly after dialysis to improve adherence 3
  • Medications removed by dialysis may need post-dialysis dosing

Medications to Avoid or Use with Caution

• Diuretics: Generally ineffective in ESRD 3
• Moxonidine: NOT recommended due to safety concerns (increased mortality) 1
• Alpha-adrenoceptor antagonists: NOT recommended due to safety concerns (neurohumoral activation, fluid retention) 1
• Diltiazem and verapamil: Should be avoided in patients with heart failure with reduced ejection fraction 1

Special Considerations

• Blood pressure targets should be individualized based on comorbidities and dialysis tolerance
• Volume control remains the cornerstone of hypertension management in ESRD 2, 8
• Consider medication removal during dialysis when selecting agents
• For non-adherent patients, consider medications that can be administered less frequently or under supervision after dialysis 3