Can Angiotensin-Converting Enzyme (ACE) inhibitors or Angiotensin Receptor Blockers (ARBs) be used in patients with End-Stage Renal Disease (ESRD) undergoing Hemodialysis (HD)?

ACE Inhibitors and ARBs in End-Stage Renal Disease Patients on Hemodialysis

ACE inhibitors and ARBs can be safely used in patients with end-stage renal disease (ESRD) undergoing hemodialysis, and may provide significant cardiovascular benefits despite the absence of kidney function. 1

Benefits of ACE Inhibitors/ARBs in Hemodialysis Patients

• ACE inhibitors and ARBs are frequently used in dialysis patients and are not contraindicated in ESRD 1
• These medications may decrease morbidity and mortality in hemodialysis patients by reducing mean arterial pressure, aortic pulse wave velocity, left ventricular hypertrophy, and potentially reducing C-reactive protein and oxidant stress 2
• ACE inhibitors have been shown to significantly reduce mortality in hemodialysis patients with a risk reduction of 52%, with even greater benefit (79% risk reduction) in patients 65 years or younger 3
• Both ACE inhibitors and ARBs appear effective in primary prevention of atrial fibrillation in ESRD patients on dialysis 4

Medication Selection and Administration

• When selecting an ACE inhibitor for hemodialysis patients, consider drugs that are not significantly dialyzed to maintain stable therapy 1
• Some ACE inhibitors (captopril, enalapril, lisinopril, perindopril) undergo substantial clearance during dialysis, making dosing and timing more complex 5
• ARBs are not dialyzable, which is an advantage over some ACE inhibitors in this population 5
• For medications with predominant renal excretion (like lisinopril and atenolol), thrice-weekly supervised administration after hemodialysis can enhance blood pressure control 2

Precautions and Monitoring

• Monitor serum potassium levels regularly, as hyperkalemia is a potential risk with both ACE inhibitors and ARBs in ESRD patients 6, 7
• The incidence of hyperkalemia (potassium ≥5.5 mEq/L) with standard doses of ACE inhibitors or ARBs in dialysis patients is approximately 13%, with higher risk in patients with inadequate dialysis 8
• ACE inhibitors should not be administered to patients treated with polyacrylonitrile dialysis membranes due to the risk of anaphylactoid dialyzer reactions 1
• Combined use of ACE inhibitors and ARBs should be avoided due to increased risk of adverse events without additional benefits 1

Advantages of ARBs vs. ACE Inhibitors in ESRD

• ARBs have a more favorable adverse effect profile compared to ACE inhibitors in ESRD patients 5
• ARBs are not associated with cough or anaphylactoid dialyzer reactions that can occur with ACE inhibitors 5
• ARBs are not dialyzable, making dosing more straightforward compared to some ACE inhibitors 5

Clinical Decision Algorithm

1. Assess cardiovascular risk factors and indications (hypertension, heart failure, atrial fibrillation prevention)
2. Check for contraindications:
   • Polyacrylonitrile dialysis membranes (for ACE inhibitors) 1
   • History of angioedema or severe cough with ACE inhibitors (consider ARB instead) 5
   • Hyperkalemia (potassium >5.5 mEq/L) 6
3. Select appropriate agent:
   • For patients at high risk of dialyzer reactions: choose ARB 5
   • For patients with history of ACE inhibitor cough: choose ARB 5
   • For patients with variable dialysis schedules: prefer ARB or non-dialyzable ACE inhibitor 1
4. Monitor:
   • Serum potassium levels regularly 6
   • Blood pressure response 2
   • Cardiovascular symptoms 3

In summary, ACE inhibitors and ARBs provide significant cardiovascular benefits in ESRD patients on hemodialysis and can be safely used with appropriate monitoring and precautions for hyperkalemia and other potential adverse effects.