What antihypertensive medications should be avoided in a patient with stage 5 Chronic Kidney Disease (CKD) undergoing regular hemodialysis?

Antihypertensives to Avoid in CKD Stage 5 on Hemodialysis

Direct renin inhibitors (aliskiren) should be avoided in CKD Stage 5 hemodialysis patients, particularly when combined with ACE inhibitors or ARBs, as this combination increases adverse events including hyperkalemia and acute kidney injury without additional benefit. 1, 2

Specific Medications to Avoid

Direct Renin Inhibitors (Aliskiren)

• Never combine aliskiren with ACE inhibitors or ARBs, especially in patients with CrCl <60 mL/min, which includes all dialysis patients 1, 2
• Avoid any triple combination of ACE inhibitor + ARB + direct renin inhibitor due to increased risk of hyperkalemia and acute kidney injury 1
• While aliskiren pharmacokinetics are not significantly altered by hemodialysis, the safety concerns regarding combination therapy make it inappropriate for this population 2

Dual RAAS Blockade

• Never combine ACE inhibitor + ARB together, as this increases adverse events (hyperkalemia, acute kidney injury) without providing additional cardiovascular benefit 1
• This prohibition is absolute in the dialysis population where potassium management is already challenging 1

Thiazide and Thiazide-Like Diuretics

• Thiazide and thiazide-like diuretics lose effectiveness when GFR falls below 30 mL/min and are essentially ineffective in Stage 5 CKD 1
• Loop diuretics (furosemide 20-80 mg twice daily or torsemide 5-10 mg once daily) are the preferred diuretic class if residual renal function exists 1

Medications Requiring Caution (Not Necessarily Avoided)

Dialyzable Antihypertensives

While not strictly contraindicated, certain medications are removed during hemodialysis and require careful timing considerations:

• Dialyzable agents include enalapril, ramipril, methyldopa, atenolol, acebutolol, nadolol, minoxidil, and nitroprusside 3
• These agents may cause paradoxical blood pressure rises during dialysis if removed by the procedure 3
• Non-dialyzable agents (preferred for consistent control) include clonidine, carvedilol, labetalol, calcium channel blockers, and ARBs 3

Older Short-Acting Agents

• Antihypertensive agents requiring three-times-daily dosing should be avoided due to high pill burden and risk of noncompliance leading to rebound hypertension 4
• Once-daily agents administered at night are preferred to control nocturnal blood pressure and minimize intradialytic hypotension 4

Recommended First-Line Agents (For Context)

The K/DOQI guidelines recommend the following hierarchy for dialysis patients 3, 5:

1. ACE inhibitors or ARBs as first-line therapy (associated with decreased mortality and reduced left ventricular hypertrophy) 3, 5
2. Beta-blockers (particularly metoprolol) for patients with coronary artery disease, prior MI, or heart failure 5, 6
3. Calcium channel blockers (particularly nifedipine) as effective second-line or add-on agents 5, 6
4. Direct vasodilators (hydralazine, minoxidil) for resistant hypertension 3, 6

Critical Monitoring When Using RAAS Inhibitors

When ACE inhibitors or ARBs are used (which is recommended as first-line), strict potassium monitoring is essential 5:

• Check serum potassium within 3-7 days of initiating or titrating 5
• Recheck at 1 week, then monthly for 3 months, then every 3 months thereafter 5
• Target potassium 4.0-5.0 mEq/L 5

Common Pitfall to Avoid

Do not routinely withhold all antihypertensives before dialysis due to concerns about intradialytic hypotension, as this practice may worsen interdialytic blood pressure control and increase prevalence of intradialytic hypertension 7. Instead, preferentially use non-dialyzable agents and administer them at night 4, 7.