From the Guidelines
Hydralazine can be used in patients with impaired renal function, but close monitoring is essential due to the potential for altered drug clearance and increased sensitivity to blood pressure medications. The standard dosing for hydralazine in adults is 100-200 mg orally two to three times daily, as indicated in the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults 1. However, for patients with severe renal impairment, dosage adjustments may be necessary, such as reducing the dose by 25-50% or extending the dosing interval. Hydralazine is primarily metabolized by the liver through acetylation, with only about 10-14% excreted unchanged in the urine, making it relatively safe in kidney disease 1.
Some key points to consider when using hydralazine in patients with renal impairment include:
- Close monitoring of blood pressure, heart rate, and kidney function is crucial
- Hydralazine can cause side effects such as headache, tachycardia, fluid retention, and rarely a lupus-like syndrome with prolonged use
- Hydralazine is often used in combination with other antihypertensives like beta-blockers to counteract reflex tachycardia
- The combination of hydralazine and nitrates has been shown to decrease mortality in patients with renal failure, as demonstrated in a narrative review on renal function monitoring in heart failure 1.
It is essential to weigh the benefits and risks of using hydralazine in patients with impaired renal function and to closely monitor their condition to minimize potential adverse effects.
From the FDA Drug Label
In hypertensive patients with normal kidneys who are treated with hydrALAZINE, there is evidence of increased renal blood flow and a maintenance of glomerular filtration rate. ... However, as with any antihypertensive agent, hydrALAZINE should be used with caution in patients with advanced renal damage.
Hydralazine can be used in patients with impaired renal function, but it should be used with caution in patients with advanced renal damage. 2
From the Research
Hydralazine Use in Impaired Renal Function
- There is no direct evidence in the provided studies to support the use of hydralazine in patients with impaired renal function.
- The studies focus on the use of other antihypertensive agents such as ACE inhibitors, angiotensin II receptor antagonists, calcium channel blockers, and diuretics in patients with chronic kidney disease or renal failure 3, 4, 5, 6.
- However, it is mentioned that antihypertensive drugs can have direct effects on intrarenal mechanisms of damage, such as increased glomerular pressure and proteinuria, and that some agents may be more suitable for use in patients with chronic renal disease than others 4.
- The use of calcium channel blockers, such as lercanidipine, has been shown to have a high antihypertensive effect in patients with chronic renal failure, with a good tolerability profile and an interesting effect on plasmatic lipids 5.
- It is also noted that renin-angiotensin-aldosterone system (RAAS) blockers are a life-saving treatment for patients with heart failure with reduced ejection fraction, regardless of worsening renal function, and that uptitration to the maximum-tolerated dose should be a constant goal 7.