What are the preferred antihypertensive agents for patients with End-Stage Renal Disease (ESRD) on dialysis?

Preferred Antihypertensive Agents for ESRD Patients on Dialysis

ACE inhibitors or ARBs should be used as first-line antihypertensive agents in most ESRD patients on dialysis, followed by calcium channel blockers and beta-blockers as needed for adequate blood pressure control. 1

Initial Management Approach

• Achievement of dry weight through ultrafiltration and dietary sodium restriction is the cornerstone of blood pressure management in dialysis patients 1
• Target predialysis blood pressure should be 140/90 mmHg (measured in sitting position) 1
• Lifestyle modifications including salt restriction should be continuously emphasized 1

First-Line Medication Selection

• ACE inhibitors or ARBs are recommended as first-line agents for most dialysis patients 1
  • These agents reduce left ventricular hypertrophy in hemodialysis patients 1
  • ACE inhibitors have been associated with decreased mortality in observational studies of ESRD patients 1
  • ARBs may be more potent than ACE inhibitors for LVH reduction 1

Special Considerations for Medication Selection

• For patients with previous myocardial infarction or established coronary artery disease, beta-blockers should be preferred 1
  • Beta-blockers are associated with decreased mortality in CKD patients 1
• Calcium channel blockers (CCBs) should be considered as part of the regimen when additional agents are needed 1
  • Observational studies suggest CCBs are associated with decreased total and cardiovascular mortality in dialysis patients 1
• For patients with residual kidney function (RKF), ACE inhibitors or ARBs are particularly beneficial 1
  • These agents slow the decline in residual kidney function in peritoneal dialysis patients 1

Pharmacokinetic Considerations

• Consider the dialyzability of medications when selecting agents 1:
  • Hemodialysis reduces blood levels of some ACE inhibitors (enalapril, ramipril) but not others (benazepril, fosinopril) 1
  • Levels of clonidine, carvedilol, labetalol, CCBs, and ARBs do not change significantly during dialysis 1
  • For patients prone to intradialytic hypotension, medications removed by dialysis may be preferred 2
  • For patients with intradialytic hypertension, non-dialyzable medications are preferred 2

Management of Resistant Hypertension

• Resistant hypertension is defined as BP >140/90 mmHg despite achieving dry weight and using three appropriate antihypertensive agents 1
• If BP remains uncontrolled with three agents, evaluate for secondary causes of resistant hypertension 1
• For severe resistant hypertension, consider adding minoxidil as a potent vasodilator 1, 3
• If hypertension remains uncontrolled after a trial with minoxidil, consider switching to peritoneal dialysis 1
• If peritoneal dialysis proves ineffective, surgical or embolic nephrectomy may be considered 1

Common Pitfalls and Caveats

• Avoid using ACE inhibitors in patients treated with polyacrylonitrile dialysis membranes due to risk of anaphylactoid reactions 1
• Monitor for hyperkalemia when using ACE inhibitors or ARBs, especially with non-selective beta-blockers 3
• Be cautious with aggressive BP lowering in elderly patients with isolated systolic hypertension 1
• Low predialysis systolic BP (<110 mmHg) and diastolic BP (<70 mmHg) are associated with increased mortality 4
• Paradoxical rise in blood pressure can occur during dialysis due to removal of certain antihypertensive drugs or excessive volume depletion 1

Medication Dosing Strategy

• For medications with predominant renal excretion (like lisinopril and atenolol), thrice-weekly supervised administration after hemodialysis can enhance BP control 3
• Most dialysis patients will require a combination of several antihypertensive drugs for adequate BP control 2, 3