What are suitable hypertensive medications for patients with end-stage renal disease (ESRD) on dialysis?

Antihypertensive Medications for Patients with End-Stage Renal Disease on Dialysis

Beta-blockers and calcium channel blockers are the most effective antihypertensive medications for patients with end-stage renal disease (ESRD) on dialysis, with demonstrated benefits on cardiovascular outcomes and mortality. 1

First-Line Medication Options

Beta-Blockers

• Demonstrated fewer heart failure hospitalizations compared to ACE inhibitors in hemodialysis patients with hypertension and left ventricular hypertrophy 1
• Lower risk of death and cardiovascular death with carvedilol versus placebo in hemodialysis patients with dilated cardiomyopathy 1
• Decrease mortality, blood pressure, and ventricular arrhythmias while improving left ventricular function in ESRD patients 2
• Recommended as first-line therapy for patients with previous myocardial infarction or established coronary artery disease 1

Calcium Channel Blockers (CCBs)

• Amlodipine reduced cardiovascular events compared with placebo in hemodialysis patients with hypertension in randomized controlled trials 1
• Associated with decreased total and cardiovascular mortality in observational studies 1, 3
• Not dialyzable and do not require dose adjustment based on renal function 3
• Both dihydropyridine and non-dihydropyridine CCBs associated with reduced risk of cardiovascular death in ESRD patients with preexisting cardiovascular disease 4

Second-Line Medication Options

ACE Inhibitors/ARBs

• May reduce left ventricular mass index according to meta-analyses 1
• May preserve residual kidney function, especially in peritoneal dialysis patients 1
• Recommended as first-line treatment in the majority of patients according to some guidelines 1
• Potential risks include hyperkalemia and anaphylactoid reactions with AN69 membranes 2

Mineralocorticoid Receptor Antagonists

• Some trials have shown cardiovascular benefits with spironolactone versus placebo, while others have not 1
• Ongoing research trials are evaluating spironolactone and cardiovascular outcomes in hemodialysis patients 1

Diuretics

• May help preserve residual diuresis and limit fluid overload in patients with remaining urine output 1
• Continuation of loop diuretics after hemodialysis initiation is associated with lower interdialytic weight gain and lower intradialytic hypotension rates 1
• Have minimal effect on central hemodynamic indices and should not be considered primary antihypertensive medications in dialysis 1

Special Considerations

Dosing Strategies

• Many blood pressure medications can be dosed once daily, preferably at night to control nocturnal blood pressure 5
• For non-compliant patients, renally eliminated agents (lisinopril, atenolol) can be given thrice weekly after hemodialysis 5
• Avoid medications requiring thrice daily dosing due to high pill burden and risk of non-compliance 5

Volume Management

• Achievement of dry weight and reduction of extracellular fluid volume should be pursued before or alongside medication therapy 1
• Salt restriction should be continuously emphasized as part of hypertension management 1
• Volume control through adequate dialysis and sodium restriction can help optimize hypertension treatment 6

Treatment Goals

• Reasonable goal for predialysis blood pressure is 140/90 mmHg (measured in sitting position) 1
• Target should avoid substantial orthostatic hypotension or symptomatic intradialytic hypotension 1

Treatment Algorithm

1. Optimize volume status through dialysis and sodium restriction 1
2. For patients with coronary artery disease or heart failure: Start with beta-blockers 1
3. For patients without specific cardiovascular indications: Start with calcium channel blockers 1, 4
4. If blood pressure remains uncontrolled, add a second agent from a different class 1
5. For resistant hypertension (BP >140/90 mmHg despite three medications), evaluate for secondary causes 1

Common Pitfalls

• Failing to assess volume status before initiating or increasing antihypertensive medications 1
• Not considering medication removal during dialysis when selecting agents and dosing schedules 5
• Overlooking the importance of preserving residual kidney function when selecting medications 1
• Using medications requiring multiple daily doses that may reduce compliance 5
• Not adjusting medication regimens to prevent intradialytic hypotension 1