From the Guidelines
Hypertension management in hemodialysis patients should prioritize a multifaceted approach focusing on both dialysis-related and pharmacological interventions to minimize morbidity, mortality, and improve quality of life. The target blood pressure for hemodialysis patients should be <140/90 mmHg before dialysis and <130/80 mmHg after dialysis, as suggested by various studies 1.
Key Components of Hypertension Management
- Optimize the dialysis prescription by ensuring adequate fluid removal to achieve dry weight, using longer or more frequent dialysis sessions if needed, as recommended by 1.
- Sodium restriction to 2g daily and limiting fluid intake to 1-1.5L per day between sessions are essential dietary modifications, as emphasized by 1.
- For pharmacotherapy, long-acting calcium channel blockers like amlodipine (5-10mg daily) or ACE inhibitors/ARBs such as lisinopril (2.5-10mg daily) or losartan (25-100mg daily) are preferred first-line agents, as suggested by 1.
- Beta-blockers like carvedilol (6.25-25mg twice daily) or metoprolol (25-200mg daily) are particularly beneficial for patients with heart failure or coronary artery disease, as noted by 1.
- Administer most antihypertensives after dialysis to prevent removal during treatment, and monitor for intradialytic hypotension, hyperkalemia with ACE inhibitors/ARBs, and adjust medication timing to maximize effectiveness, as recommended by 1.
Recent Evidence and Considerations
A recent study from 2020 1 highlights the importance of blood pressure control in patients with chronic kidney disease, including those on hemodialysis, but also notes the potential risks of overly aggressive blood pressure control in this population. The method of measurement of blood pressure may also be important in prognostication, with home blood pressure monitoring being superior to office blood pressure monitoring in diagnosing hypertension and reducing the incidence of white coat hypertension and masked hypertension, as found by 1.
Conclusion is not allowed, so the answer will be ended here.
From the FDA Drug Label
- 4 Hypotension Lisinopril can cause symptomatic hypotension, sometimes complicated by oliguria, progressive azotemia, acute renal failure or death Patients at risk of excessive hypotension include those with the following conditions or characteristics: heart failure with systolic blood pressure below 100 mmHg, ischemic heart disease, cerebrovascular disease, hyponatremia, high dose diuretic therapy, renal dialysis, or severe volume and/or salt depletion of any etiology
Lisinopril can cause hypotension in patients undergoing renal dialysis. Patients at risk of excessive hypotension include those with renal dialysis.
- Key points:
- Lisinopril can cause symptomatic hypotension
- Patients undergoing renal dialysis are at risk of excessive hypotension
- Lisinopril should be started under very close medical supervision in these patients 2
From the Research
Hypertension in Hemodialysis Patients
- Hypertension is a common condition in end-stage renal disease (ESRD) patients, with the majority of patients being hypertensive 3, 4, 5, 6.
- The pathophysiology of hypertension in ESRD is complex and multifactorial, involving various mechanisms such as fluid overload, sodium retention, and activation of the renin-angiotensin-aldosterone system 4, 5.
Treatment of Hypertension in Hemodialysis Patients
- Antihypertensive medications are often necessary to control blood pressure in hemodialysis patients, with multiple drugs often required to achieve adequate blood pressure control 3, 5.
- Angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers may be beneficial in reducing left ventricular mass and improving cardiovascular outcomes 3, 4.
- Calcium channel blockers are also effective in lowering blood pressure and reducing cardiovascular mortality in hemodialysis patients 3, 7.
- Beta-blockers can decrease mortality, blood pressure, and ventricular arrhythmias, and improve left ventricular function in ESRD patients 3.
Risks and Complications of Antihypertensive Therapy in Hemodialysis Patients
- Antihypertensive medications can increase the risk of intradialytic hypotension, particularly with the use of beta-blockers, ACE inhibitors, and diuretics 7.
- Hyperkalemia, anaphylactoid reactions, and aggravation of renal anemia are potential risks associated with certain antihypertensive medications in hemodialysis patients 3.
Monitoring and Management of Blood Pressure in Hemodialysis Patients
- Regular monitoring of blood pressure, including predialysis and postdialysis measurements, is essential to manage hypertension in hemodialysis patients 4.
- Interdialytic ambulatory blood pressure monitoring (ABPM) may be useful in selected patients to determine the presence of hypertension and to monitor the effectiveness of treatment 4.
- Home blood pressure monitoring and yearly echocardiography are also recommended to monitor cardiovascular risk factors and to adjust treatment as needed 4.