What medications are suitable for a dialysis patient with hypertension?

Antihypertensive Medications for Dialysis Patients

First-line medications for hypertension in dialysis patients are ACE inhibitors or ARBs, followed by calcium channel blockers as second-line therapy, and beta-blockers as third-line options. 1

Volume Control: The Foundation of BP Management

Before intensifying medication therapy, volume control is essential:

• Achieve dry weight through sodium restriction (2-3 g/day)
• Maximize ultrafiltration during dialysis
• Regular dietitian counseling (every 3 months)

Volume overload underlies most cases of BP elevation in dialysis patients, making non-pharmacologic treatments the initial approach. 2, 1

Medication Selection Algorithm

First-Line: ACE Inhibitors/ARBs

• Benefits: Regression of left ventricular hypertrophy, reduced sympathetic activity, improved endothelial function 1
• Example: Lisinopril 2.5mg alternate day or once-weekly (post-dialysis administration) 1
• Monitoring: Regular serum potassium to prevent hyperkalemia

Second-Line: Calcium Channel Blockers

• Non-dialyzable options preferred 1
• Example: Amlodipine 5-10mg once-daily 1
• Benefits: Vasodilation, reduction in peripheral vascular resistance, and improved glomerular filtration rate 3
• Amlodipine has minimal effect on heart rate and has a long half-life (30-50 hours) making it suitable for dialysis patients 3

Third-Line: Beta-Blockers

• Particularly beneficial if cardiovascular disease is present 1
• Non-dialyzable options like carvedilol preferred 1
• Benefits: Decrease mortality, blood pressure, and ventricular arrhythmias 4

Special Considerations

Medication Timing

• Administer antihypertensive drugs preferentially at night to reduce nocturnal BP surge and minimize intradialytic hypotension 1

Dialyzability of Medications

• Non-dialyzable medications preferred: clonidine, carvedilol, labetalol, most CCBs, and ARBs 1
• Dialyzable medications (some ACE inhibitors and beta blockers) may require post-dialysis dosing 1
• One retrospective study found that non-dialyzable β-blockers (e.g., propranolol) were associated with lower mortality risk compared to highly dialyzable β-blockers (e.g., atenolol, metoprolol) 2

Blood Pressure Monitoring

• Home BP monitoring or ambulatory BP monitoring provides more reliable assessment than in-center measurements 1
• Monitor pre-dialysis, intradialytic, and post-dialysis blood pressure 1
• Define intradialytic hypertension as an SBP increase of >10 mm Hg from pre- to post-dialysis 2

Management of Resistant Hypertension

Resistant hypertension (BP >140/90 mmHg despite dry weight achievement and three antihypertensive agents) requires:

• Ensuring volume control
• Using combination therapy
• Additional agents: Alpha-adrenergic blockers or Minoxidil (for severe cases) 1, 5

Common Pitfalls to Avoid

1. Neglecting volume control before intensifying medication therapy
2. Failing to adjust medications for dialysis schedule
3. Administering dialyzable medications before dialysis sessions
4. Excessive BP reduction leading to intradialytic hypotension
5. Not monitoring for hyperkalemia with ACE inhibitors/ARBs 1

Remember that low predialysis systolic BP (<110 mm Hg) and diastolic BP (<70 mm Hg) are associated with increased mortality, primarily due to severe congestive heart failure or coronary artery disease 6. Therefore, while controlling hypertension is important, avoiding excessive BP reduction is equally critical.