What is the best approach for managing hypertension in patients with End-Stage Renal Disease (ESRD)?

Hypertension Management in End-Stage Renal Disease (ESRD)

In patients with ESRD, blood pressure management should focus on volume control through ultrafiltration and dietary sodium restriction as the primary strategy, followed by medication therapy with renin-angiotensin system (RAS) blockers as first-line agents when additional control is needed. 1

Blood Pressure Targets in ESRD

• For ESRD patients on dialysis, lowering both systolic and diastolic blood pressure has been shown to reduce cardiovascular events, cardiovascular death, and all-cause mortality 2
• While specific BP targets in ESRD remain somewhat controversial, evidence suggests aiming for SBP <140 mmHg as a reasonable target 2
• In patients with ESRD who have undergone kidney transplantation, a BP goal of less than 130/80 mmHg is reasonable 2

Primary Treatment Strategy

• Volume control through ultrafiltration and dietary sodium restriction represents the cornerstone of hypertension management in ESRD 1, 3
• Therapeutic adjustments should avoid excessive volume depletion to minimize hypotension during dialysis 2
• After establishing appropriate volume control, pharmacological therapy should be added if BP remains elevated 1, 3

Pharmacological Management

First-Line Agents

• RAS blockers (ACE inhibitors or ARBs) are preferred first-line agents due to their cardioprotective effects beyond BP reduction 1, 3
• In the RENAAL study, losartan significantly reduced proteinuria by an average of 34% and slowed the decline in glomerular filtration rate by 13% in diabetic nephropathy patients 4
• Beta-blockers are also reasonable first-line agents for most ESRD patients 1

Combination Therapy

• Multiple antihypertensive drugs are often necessary to achieve effective BP control in dialysis patients 3
• Calcium channel blockers combined with RAS blockers have shown superior efficacy in preventing doubling of serum creatinine and ESRD progression compared to thiazide diuretics with RAS blockers 2
• Loop diuretics should replace thiazides if serum creatinine is >1.5 mg/dL or eGFR is <30 mL/min/1.73 m² 2

Medication Considerations in Dialysis

• Consider the dialyzability of medications when selecting agents 1
• Non-dialyzable medications may be preferred in patients prone to intradialytic hypotension 1
• For non-adherent patients, thrice-weekly dosing of medications after dialysis can still provide effective BP control 1

Special Considerations

• Avoid combination of two RAS blockers despite potentially greater antiproteinuric effects due to increased risk of adverse events 2
• Mineralocorticoid receptor antagonists are generally not recommended in ESRD, especially in combination with RAS blockers, due to risk of hyperkalemia 2
• Intradialytic hypertension can be managed by reassessing dry weight and using non-dialyzable medications 1
• High medication adherence (≥80%) to antihypertensive agents is associated with significant risk reduction of ESRD progression 5

Monitoring and Follow-up

• Regular monitoring of serum potassium levels is essential, especially with RAS blockers 2
• Monitor for signs of intradialytic hypotension, which may require adjustment of antihypertensive regimen 1
• Assess home blood pressure readings when possible, as dialysis unit measurements may not correlate well with cardiovascular outcomes 1, 6

Treatment-Resistant Hypertension

• For resistant hypertension in ESRD, consider increasing dialysis frequency or duration 3
• In extreme cases of malignant hypertension not responding to conventional therapy, kidney transplantation may be considered as a definitive treatment 7
• After successful kidney transplantation, hypertension often improves significantly, allowing reduction in antihypertensive medications 7