What is the first-line treatment for hypertension in a patient undergoing hemodialysis, considering options such as Angiotensin-Converting Enzyme (ACE) inhibitors or Angiotensin Receptor Blockers (ARBs) versus beta blockers?

First-Line Antihypertensive Treatment in Hemodialysis Patients

ACE inhibitors or ARBs are recommended as first-line treatment for hypertension in hemodialysis patients. 1, 2

Initial Management Approach

• Achievement of dry weight through ultrafiltration and dietary sodium restriction should be the cornerstone of blood pressure management in dialysis patients 1, 2
• Target predialysis blood pressure should be 140/90 mmHg (measured in sitting position) 1
• Lifestyle modifications including salt restriction should be continuously emphasized before initiating pharmacological therapy 1

First-Line Medication Selection Algorithm

1. First-line agents: ACE inhibitors or ARBs for most hemodialysis patients 1, 2

   • 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, 3
   • ARBs may be more potent than ACE inhibitors for LVH reduction 1, 4

2. Special considerations:

   • For patients with previous myocardial infarction or established coronary artery disease, beta-blockers should be preferred as first-line agents 1, 2
   • Beta-blockers are associated with decreased mortality in CKD patients and improve left ventricular function 1, 5

Pharmacokinetic Considerations

• Consider the dialyzability of medications when selecting specific agents 2, 3
• Hemodialysis reduces blood levels of some ACE inhibitors (enalapril, ramipril) but not others (benazepril, fosinopril) 2
• Lisinopril can be removed by hemodialysis 6
• For patients with poor medication adherence, consider renally eliminated agents (lisinopril, atenolol) that can be administered thrice weekly after dialysis sessions 7, 3

Combination Therapy

• If blood pressure is not controlled with a single agent, add a second or third drug of a different class 1
• Calcium channel blockers and anti-alpha-adrenergic drugs should be added when additional agents are needed 1, 3
• Observational studies suggest calcium channel blockers are associated with decreased total and cardiovascular mortality in dialysis patients 1, 5
• Avoid simultaneous use of ACE inhibitors and ARBs as this combination increases risk of hyperkalemia and acute kidney injury without additional benefit for hypertension treatment 1

Common Pitfalls and Caveats

• Avoid using ACE inhibitors in patients treated with polyacrylonitrile (AN69) dialysis membranes due to risk of anaphylactoid reactions 2, 5
• Monitor serum potassium levels regularly when using ACE inhibitors or ARBs due to increased risk of hyperkalemia 1
• Be cautious with aggressive BP lowering in elderly patients with isolated systolic hypertension 2
• Paradoxical rise in blood pressure can occur during dialysis due to removal of certain antihypertensive drugs 2
• Older antihypertensive agents requiring thrice daily dosing should be avoided due to high pill burden and risk of non-compliance 8

Management of Resistant Hypertension

• Resistant hypertension is defined as BP >140/90 mmHg despite achieving dry weight and using three appropriate antihypertensive agents 1, 2
• If BP remains uncontrolled with three agents, evaluate for secondary causes of resistant hypertension 1, 2
• For severe resistant hypertension, consider adding minoxidil as a potent vasodilator 1, 5
• If hypertension remains uncontrolled after a trial with minoxidil, consider switching to peritoneal dialysis 1