From the Guidelines
Antihypertensive medications should be held on dialysis days if they interfere with ultrafiltration (UF) or if the patient's blood pressure is well controlled, as stated in the Kidney Disease: Improving Global Outcomes (KDIGO) controversies conference 1. When considering the management of antihypertensive medications on dialysis days, it's crucial to prioritize the patient's blood pressure control, volume status, and overall cardiovascular health.
- The decision to hold or continue antihypertensive medications should be individualized based on the patient's specific needs and medical history.
- Patients with poorly controlled hypertension or those who experience hypertension during dialysis may require continued antihypertensive medication, as stated in the KDIGO conference 1.
- The timing of antihypertensive medication administration should be tailored to the patient's interdialytic blood pressure and frequency of intradialytic hypotension, as suggested in the study published in Kidney International 1.
- It is reasonable to choose antihypertensive medications based on patient characteristics, cardiovascular indications, and availability, considering pharmacokinetics and dialyzability, as discussed in the study 1.
- After dialysis, patients should resume their regular antihypertensive schedule unless otherwise instructed by their nephrologist, ensuring consistent blood pressure control and minimizing the risk of complications. The rationale for holding antihypertensive medications on dialysis days is to prevent excessive hypotension during treatment, which can lead to symptomatic hypotension, causing dizziness, nausea, cramping, or even syncope during the procedure, as mentioned in the study 1.
From the Research
Holding Anti-Hypertensive Medication on Dialysis Day
- The decision to hold anti-hypertensive medication on dialysis day is complex and depends on various factors, including the patient's individual needs and medical history 2, 3.
- Current guidelines recommend antihypertensive medications be given at night and held the morning of dialysis for affected patients, but there is little evidence to support this recommendation 2.
- Withholding BP medications before hemodialysis should not be a routine practice, as it may worsen interdialytic blood pressure control and increase the prevalence of euvolemic intradialytic hypertension (ID-HTN) 3.
- A study found that taking BP medications before hemodialysis was not noninferior to holding BP medications for the primary outcome of intradialytic hypotension (IDH), but did reduce the occurrence of uncontrolled hypertension 4.
Factors to Consider
- The type of antihypertensive medication used can affect the risk of intradialytic hypotension, with calcium channel blockers associated with a lower risk compared to other types of medications 5.
- The patient's comorbidities, pharmacokinetics of the drug, and its dialyzability should be considered when selecting an antihypertensive medication 3, 6.
- Control of extracellular volume with ultrafiltration and dietary sodium restriction represents the principal strategy to manage hypertension in end-stage renal disease (ESRD), and antihypertensive medications are subsequently added if this strategy is inadequate 6.
Clinical Considerations
- Intradialytic hypotension is a prevalent yet serious complication of hemodialysis, associated with decreased quality of life, inadequate dialysis, vascular access thrombosis, global hypoperfusion, and increased cardiovascular and all-cause mortality 2.
- Intradialytic hypertension can be managed by challenging the patient's dry weight and using nondialyzable medications 6.
- The timing of antihypertensive medication administration can affect the risk of intradialytic hypotension and other outcomes, and should be individualized based on the patient's needs and medical history 4.