From the Research
Hydralazine dosing for patients with end-stage renal disease (ESRD) typically does not require significant adjustment, with a recommended starting dose of 10-25 mg orally three to four times daily, titrated up to a maximum of 300 mg daily based on blood pressure response and tolerability 1.
Key Considerations
- Hydralazine is metabolized primarily by the liver through acetylation, with only about 10-14% excreted unchanged by the kidneys, resulting in minimal impact of severe renal impairment on its clearance 2.
- Patients on dialysis may experience more pronounced blood pressure fluctuations, making careful monitoring essential, particularly during and immediately after dialysis sessions when fluid shifts occur 3.
- Side effects to watch for include headache, tachycardia, and fluid retention, which may be more problematic in ESRD patients with limited cardiac reserve 1.
- For patients who develop a lupus-like syndrome (more common with doses exceeding 200 mg daily), dose reduction or discontinuation may be necessary 2.
- Hydralazine is dialyzable but supplemental doses after dialysis are generally not required due to its short half-life and frequent dosing schedule 1.
Recent Study Findings
- A 2020 pilot trial found that combination therapy with isosorbide dinitrate and hydralazine was well-tolerated in patients with ESRD on maintenance hemodialysis, with a maximum tolerated dose of 40/75 mg three times per day 1.
- A 2024 study demonstrated that early up-titration of hydralazine combined with conventional treatment improved outcomes in patients with severe systolic dysfunction and significant mitral regurgitation, with a mean dose of 191 mg at index admission and 264 mg at study end 4.
Clinical Implications
- The dosing of hydralazine in ESRD patients should be individualized based on blood pressure response and tolerability, with careful monitoring for potential side effects and adjustments made as needed 1, 4.
- The use of hydralazine in combination with other antihypertensive agents, such as isosorbide dinitrate, may be beneficial in achieving optimal blood pressure control and reducing cardiovascular risk in ESRD patients 1, 4.