Can you use Angiotensin-Converting Enzyme Inhibitors (ACEIs) in patients undergoing dialysis?

Use of ACE Inhibitors in Dialysis Patients

ACE inhibitors can be used in dialysis patients, but require careful dosing, monitoring, and consideration of specific risks including hypotension and hyperkalemia. 1

Benefits of ACE Inhibitors in Dialysis Patients

ACE inhibitors provide several benefits for dialysis patients:

• Improve survival in patients with heart failure and reduced left ventricular ejection fraction 1
• May preserve residual kidney function, especially in peritoneal dialysis patients 1
• Help manage hypertension in dialysis patients 2
• Recommended for dialysis patients with heart failure and impaired left ventricular function 1

Risks and Considerations

When using ACE inhibitors in dialysis patients, several important risks must be managed:

• Hypotension: 30% dropout rate due to hypotension was observed in one study of dialysis patients on enalapril 1
• Hyperkalemia: Dialysis patients are at higher risk of developing hyperkalemia with ACE inhibitors 1
• Anaphylactoid reactions: Can occur during dialysis with high-flux membranes in patients on ACE inhibitors 3, 4
• Dosing considerations: Many ACE inhibitors are dialyzable, requiring post-dialysis administration 2

Practical Recommendations

Medication Selection

• Choose non-dialyzable ACE inhibitors when possible to maintain stable therapy 1
• Consider lisinopril at 2.5mg alternate day or once-weekly with post-dialysis administration 2
• Carvedilol has stronger evidence for mortality benefit in dialysis patients with heart failure than ACE inhibitors 1

Dosing Strategy

1. Start with low doses and titrate carefully 1
2. Administer preferentially at night to reduce nocturnal BP surge and minimize intradialytic hypotension 2
3. For dialyzable ACE inhibitors, administer after dialysis sessions 2
4. Individualize dosing schedules around dialysis sessions to avoid intradialytic hypotension 1

Monitoring Requirements

• Check serum potassium regularly to prevent hyperkalemia 2
• Monitor blood pressure before, during, and after dialysis 2
• Assess for symptoms of hypotension, especially during dialysis sessions 1
• Avoid using ACE inhibitors with polyacrylonitrile dialysis membranes due to risk of anaphylactoid reactions 1

Special Situations

Contraindications

• Previous anaphylactoid reactions during dialysis with ACE inhibitors 3, 4
• Severe, uncontrolled hyperkalemia 3
• Use with polyacrylonitrile dialysis membranes 1

Alternatives When ACE Inhibitors Cannot Be Used

• Angiotensin receptor blockers (ARBs) may be considered but have similar hyperkalemia risks 5
• Calcium channel blockers are recommended as second-line agents for hypertension in dialysis patients 2
• Beta-blockers, particularly carvedilol, have stronger evidence for mortality benefit in dialysis patients with heart failure 1

Common Pitfalls to Avoid

• Administering dialyzable ACE inhibitors before dialysis sessions 2
• Failing to adjust medications for dialysis schedule 2
• Not monitoring for hyperkalemia 2
• Excessive BP reduction leading to intradialytic hypotension 2
• Using ACE inhibitors with polyacrylonitrile dialysis membranes 1

By following these guidelines, ACE inhibitors can be safely and effectively used in dialysis patients to manage hypertension and heart failure while minimizing risks.