What antihypertensives should be avoided in patients with End-Stage Renal Disease (ESRD)?

Antihypertensives to Avoid in ESRD Patients

In ESRD patients, avoid dual RAAS blockade (combining ACE inhibitors with ARBs or direct renin inhibitors), potassium-sparing diuretics including aldosterone antagonists in most cases, and thiazide diuretics due to lack of efficacy, while standard-dose beta-blockers should be reduced by 50%. 1

Primary Contraindications

Dual RAAS Blockade (Strongest Evidence)

• Never combine ACE inhibitors with ARBs or direct renin inhibitors - this combination significantly increases risks of hyperkalemia and acute kidney injury without providing cardiovascular or renal benefits 1, 2
• The combination of ACE inhibitors and ARBs showed higher adverse event rates (hyperkalemia and/or AKI) in clinical trials with no added benefit on CVD or CKD outcomes 1
• Direct renin inhibitors (aliskiren) should not be used with ACE inhibitors or ARBs due to increased hyperkalemia risk in CKD and potential acute renal failure 1

Potassium-Sparing Agents

• Avoid potassium-sparing diuretics (amiloride, triamterene) in patients with significant CKD (eGFR <45 mL/min/1.73 m²) 1
• Aldosterone antagonists (spironolactone, eplerenone) should be avoided with K+ supplements, other K+-sparing diuretics, or significant renal dysfunction 1
• While mineralocorticoid receptor antagonists may have benefits in resistant hypertension, they carry substantial hyperkalemia risk in ESRD and require extremely careful monitoring if used 1

Thiazide Diuretics

• Thiazide diuretics are ineffective in advanced CKD (eGFR <30 mL/min/1.73 m²) and should be avoided 1
• Loop diuretics (furosemide, bumetanide, torsemide) are preferred over thiazides in patients with moderate-to-severe CKD (GFR <30 mL/min) 1

Medications Requiring Dose Adjustment (Not Avoided, But Caution Required)

Beta-Blockers

• Reduce dose by 50% in patients with GFR <30 mL/min/1.73 m² 1
• Lisinopril and atenolol have predominant renal excretion with prolonged half-life in ESRD, allowing thrice-weekly supervised administration after hemodialysis 3
• Beta-blockers can decrease mortality and improve left ventricular function in ESRD patients but nonselective agents may increase serum potassium 3

ACE Inhibitors and ARBs (Use With Caution, Not Avoided)

• ACE inhibitors and ARBs are NOT contraindicated in ESRD - they remain nephroprotective even at GFR <30 mL/min/1.73 m² and should not be routinely discontinued 1
• These agents are frequently used in dialysis patients and can provide cardiovascular benefits 1, 3
• Start at lower doses in patients with GFR <45 mL/min/1.73 m², assess GFR and potassium within 1 week of starting 1
• Temporarily suspend during intercurrent illness, IV radiocontrast administration, bowel preparation, or major surgery 1

Special Considerations for ESRD

Dialysis-Specific Issues

• Avoid ACE inhibitors in patients treated with polyacrylonitrile dialysis membranes due to risk of anaphylactoid reactions 1
• Most antihypertensive classes can be used in dialysis patients except diuretics (which lack efficacy) 3
• Combination therapy with multiple agents is often necessary in ESRD patients 3, 4

Preferred Agents in ESRD

• Calcium channel blockers are associated with lower total and cardiovascular-specific mortality in hemodialysis patients 3
• Minoxidil is reserved for severe hypertension in dialysis patients 3
• Transdermal clonidine once weekly may benefit noncompliant dialysis patients 3

Critical Monitoring Parameters

• Monitor serum potassium closely when using any RAAS inhibitor in ESRD, particularly with concurrent use of other medications that affect potassium 1
• Assess for hyperkalemia risk factors: K+ supplements, other K+-sparing drugs, or unstable renal function 1
• Watch for acute renal failure risk in patients with suspected bilateral renal artery stenosis when using ACE inhibitors or ARBs 1