From the Guidelines
For a patient with end-stage renal disease (ESRD) and severely elevated systolic blood pressure of 200 mmHg, loop diuretics such as furosemide are often considered first-line therapy due to their effectiveness in managing volume overload and hypertension in this population. According to the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults 1, loop diuretics like furosemide are preferred over thiazides in patients with moderate-to-severe chronic kidney disease (CKD), which includes those with ESRD. The usual dose of furosemide can range from 20 to 80 mg per day, divided into two doses.
Key considerations in managing hypertension in ESRD patients include:
- Volume status: Loop diuretics are effective in managing volume overload, which is common in ESRD patients.
- Potassium levels: Close monitoring of potassium levels is necessary when using certain antihypertensive medications, such as ACE inhibitors or ARBs, in combination with diuretics.
- Kidney function: Medications that are renally cleared may require dose adjustment in patients with ESRD.
Other antihypertensive agents, such as beta-blockers (e.g., metoprolol) or alpha-blockers, may be considered based on individual patient characteristics, such as the presence of heart failure or coronary artery disease. However, the primary goal is to control blood pressure while minimizing the risk of adverse effects, particularly in patients with compromised renal function. The 2019 ESC guidelines on diabetes, pre-diabetes, and cardiovascular diseases developed in collaboration with the EASD 1 also emphasize the importance of blood pressure control in reducing the risk of micro- and macrovascular complications, although the specific recommendations may vary depending on the presence of diabetes.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Treatment Options for ESRD Patients with High Blood Pressure
- For ESRD patients with a systolic blood pressure (SBP) of 200, the treatment options are crucial to manage their condition effectively.
- According to the study 2, in hypertensive patients with reduced glomerular filtration rate (GFR), neither amlodipine nor lisinopril was superior to chlorthalidone in reducing the rate of development of end-stage renal disease (ESRD) or a 50% or greater decrement in GFR.
Combination Therapy for Hypertension
- The study 3 suggests that combining two different classes of antihypertensive drugs, such as angiotensin II receptor blockers (ARBs) and calcium channel blockers (CCBs), has an additive effect on lowering blood pressure without increasing adverse events.
- The combination of amlodipine and an angiotensin II receptor blocker has been shown to be effective in managing hypertension, with better efficacy and tolerability compared to individual agents or other combinations 4.
- Additionally, the combination of amlodipine and a renin-angiotensin-aldosterone system blocker may further reduce cardiovascular risk by improving endothelial function 5.
Specific Medications for ESRD Patients
- Olmesartan, an ARB, is available as a dual fixed-dose combination with either amlodipine or hydrochlorothiazide, and has been shown to have increased blood pressure-lowering efficacy 3.
- However, the study 2 found that amlodipine was not superior to chlorthalidone in reducing the incidence of ESRD in patients with mild or moderate-severe reduction in GFR.
- Perindopril, an angiotensin-converting enzyme inhibitor, has been shown to be superior to amlodipine in reducing vascular endothelial dysfunction when co-administered with angiotensin receptor blockers in patients with essential hypertension 6.