What are the latest guidelines for managing accelerated hypertension in the ICU for a patient with End-Stage Renal Disease (ESRD) on dialysis?

Management of Accelerated Hypertension in ICU Patients with ESRD on Dialysis

For ESRD patients on dialysis presenting with accelerated hypertension in the ICU, aggressive volume management through ultrafiltration and sodium restriction should be the primary intervention, followed by pharmacologic therapy with renin-angiotensin system blockers (ACE inhibitors or ARBs) and beta-blockers as first-line agents, with continuation of antihypertensives through the dialysis session rather than routine withholding.

Primary Management Strategy: Volume Control

• Extracellular volume control through ultrafiltration and dietary sodium restriction represents the principal strategy for managing hypertension in ESRD patients 1
• Challenge the patient's dry weight aggressively, as volume overload is the predominant mechanism driving hypertension in dialysis patients 1
• Antihypertensive medications should be added only after volume management strategies prove inadequate 1

Pharmacologic Therapy Algorithm

First-Line Agents

ACE inhibitors, ARBs, and beta-blockers are reasonable first-line agents for most ESRD patients with accelerated hypertension 1

• ACE inhibitors and ARBs provide cardioprotective effects independent of blood pressure reduction, including decreased mean arterial pressure, reduced left ventricular hypertrophy, and potentially lower C-reactive protein and oxidative stress 2
• Beta-blockers decrease mortality, blood pressure, ventricular arrhythmias, and improve left ventricular function in ESRD patients 2
• These drug classes target the overactive renin-angiotensin-aldosterone system and sympathetic tone characteristic of dialysis patients 3

Medication Timing Considerations

Do NOT routinely withhold antihypertensives prior to dialysis sessions 4

• Withholding antihypertensives may worsen interdialytic blood pressure control and increase prevalence of intradialytic hypertension 4
• Intradialytic hypertension portends poor cardiovascular prognosis and reflects higher hypertension burden 4
• Predialysis administration of antihypertensives is appropriate and necessary in most situations 4

Drug Selection Based on Dialyzability

For patients prone to intradialytic hypotension, prefer medications that are removed with dialysis 1

• Lisinopril and atenolol have predominant renal excretion and prolonged half-lives in ESRD, allowing thrice-weekly supervised administration after hemodialysis for enhanced blood pressure control 2
• This dosing strategy can be particularly useful in nonadherent patients 1

For patients with intradialytic hypertension, use nondialyzable medications 1

Additional Agents When Needed

• Calcium channel blockers are associated with lower total and cardiovascular-specific mortality in hemodialysis patients 2
• Calcium channel blockers address the high calcium influx in vascular smooth muscle cells characteristic of dialysis patients 3
• Minoxidil is reserved for severe, resistant hypertension in dialysis patients 2
• For nonadherent patients, transdermal clonidine once weekly may be beneficial 2

Combination Therapy

• Multiple antihypertensive drugs are often necessary to achieve adequate blood pressure control in dialysis patients 5, 2
• Combination therapy should preferably be based on renin-angiotensin system blockers, beta-blockers, and calcium channel blockers 3
• Other antihypertensive drug classes can play a complementary role 3

Critical Caveats and Monitoring

Potential Complications with ACE Inhibitors/ARBs

• Monitor for hyperkalemia, particularly with nonselective beta-blockers which can further increase serum potassium during fasting or exercise 2
• Watch for anaphylactoid reactions with AN69 membranes, particularly with ACE inhibitors 2
• Monitor for potential aggravation of renal anemia 2

Pharmacokinetic Considerations

• Pharmacokinetics are altered by impaired kidney function and dialyzability, influencing appropriate dosage, timing, and frequency of administration 3
• Within a single antihypertensive class, there may be large variability in drug removal with dialysis, which must be considered during medication selection 1
• Physicians must be familiar with pharmacokinetic properties of antihypertensive drugs in renal failure and adjust dosages accordingly 5

Blood Pressure Monitoring Challenges

• Poor correlation exists between blood pressures obtained in the dialysis unit versus home measurements and cardiovascular outcomes 1
• Intradialytic changes in blood pressure complicate management 1
• Missed dialysis treatments significantly impact blood pressure control 1