What are the latest guidelines for managing hypertension in patients with End-Stage Renal Failure (ESRF)?

Hypertension Management in End-Stage Renal Failure (ESRF)

Blood Pressure Target

Target blood pressure <130/80 mmHg in ESRF patients, with evidence supporting even lower targets (mean arterial pressure <92 mmHg, approximately 120/80 mmHg) particularly in those with proteinuria. 1, 2, 3

• In ESRF patients on dialysis, lowering both systolic and diastolic blood pressure reduces cardiovascular events, cardiovascular death, and all-cause mortality 3
• For post-kidney transplant patients, the target is specifically <130/80 mmHg 3
• Avoid systolic BP <120 mmHg in elderly patients (>65 years), where a range of 130-139 mmHg is more appropriate 1

First-Line Pharmacological Management

Volume Control as Primary Strategy

Volume management through ultrafiltration and dietary sodium restriction represents the cornerstone of hypertension treatment in ESRF, before adding antihypertensive medications. 4, 5, 6

• Achieve dry weight through additional ultrafiltration even without clinical signs of volume overload 5
• Strict dietary salt restriction combined with individually lowered dialysate sodium 5
• This approach often allows marked reduction or elimination of antihypertensive medications 5

Preferred Antihypertensive Agents

When medications are needed after volume optimization, use ACE inhibitors or ARBs as first-line agents, followed by calcium channel blockers and loop diuretics. 1, 2, 3, 4

ACE Inhibitors or ARBs (First Choice)

• Provide both blood pressure control and cardioprotection independent of BP reduction 2, 4
• Reduce proteinuria and preserve kidney function in pre-dialysis CKD 2
• ARBs are appropriate alternatives if ACE inhibitors are not tolerated 3
• In diabetic nephropathy with ESRF, losartan reduced the composite endpoint of doubling serum creatinine, ESRD, or death by 16%, and reduced ESRD alone by 29% 7

Calcium Channel Blockers (Second Choice)

• Particularly beneficial post-kidney transplantation due to improved GFR and kidney survival 3
• Combination of CCB with RAS blockers shows superior efficacy in preventing ESRD progression compared to thiazide-diuretic combinations 3
• CCB-diuretic combination achieved the highest percentage of BP control (40%) in ESRF patients 8

Loop Diuretics (Third Choice)

• Must use loop diuretics (furosemide 20-80 mg daily or torsemide 10-20 mg daily) instead of thiazides when eGFR <30 mL/min/1.73m² or serum creatinine >1.5 mg/dL, as thiazides lose efficacy 2, 3

Beta-Blockers (Conditional Use)

• Reasonable first-line agents alongside ACE inhibitors/ARBs 4
• Add only if compelling indications exist: coronary artery disease, heart failure, or post-myocardial infarction 2
• Atenolol requires dose reduction: 50 mg daily if CrCl 15-35 mL/min; 25 mg daily if CrCl <15 mL/min 2
• Carvedilol or metoprolol succinate preferred if heart failure coexists 2

Critical Monitoring Requirements

Check renal function and potassium before initiation and recheck 1-2 weeks after starting and after each dose increase. 2

• Regular monitoring of serum potassium is essential, especially with RAS blockers 3
• Monitor for intradialytic hypotension, which may require medications that are removed with dialysis 4
• Home BP monitoring is more reliable than dialysis unit measurements for predicting cardiovascular outcomes 4

Absolute Contraindications and Pitfalls

Never combine ACE inhibitor + ARB + aldosterone antagonist—this triple combination is potentially harmful and increases risk of hyperkalemia and acute kidney injury. 2

• Avoid routine ACE inhibitor + ARB combination, as this increases adverse renal events and hyperkalemia without mortality benefit 2, 3
• Mineralocorticoid receptor antagonists are generally not recommended in ESRD, especially with RAS blockers, due to hyperkalemia risk 3
• Do not use thiazide diuretics when eGFR <30 mL/min/1.73m²—they are ineffective 2, 3

Special Considerations for Dialysis Patients

Consider medication removal with dialysis when selecting agents—medications removed during dialysis may be preferred in patients prone to intradialytic hypotension. 4

• Thrice-weekly dosing after dialysis has robust BP-lowering effects and may improve adherence 4
• Intradialytic hypertension requires challenging dry weight and using non-dialyzable medications 4
• Long, slow, or frequent dialysis sessions (home HD, nocturnal HD) result in BP reduction and left ventricular hypertrophy regression 5

Treatment Algorithm

1. Optimize volume status first: Achieve dry weight through ultrafiltration and sodium restriction (<2g/day) 5, 6
2. If BP remains ≥140/90 mmHg: Add ACE inhibitor or ARB 1, 2, 3
3. If BP remains ≥140/90 mmHg: Add calcium channel blocker 3, 8
4. If BP remains ≥140/90 mmHg: Add loop diuretic (never thiazide if eGFR <30) 2, 3
5. If compelling cardiac indication: Add beta-blocker at any step 2, 4
6. Target achieved: <130/80 mmHg (or 130-139/80 mmHg if >65 years) 1, 3