What are the recommended dosages and frequencies for antihypertensive medications, including Lisinopril, Fosinopril, Benazepril, Telmisartan, Amlodipine, Nifedipine, Cilnidipine, Metoprolol, Carvedilol, Furosemide, Torsemide, Hydralazine, Isosorbide dinitrate, Clonidine, and Minoxidil, in a patient with Chronic Kidney Disease (CKD) stage 5 on regular hemodialysis?

Antihypertensive Dosing in CKD Stage 5 on Hemodialysis

For hemodialysis patients, start with ACE inhibitors or ARBs as first-line therapy, using non-dialyzable agents when possible, and expect to require 3 or more medications to achieve blood pressure control of <140/90 mmHg. 1, 2

ACE Inhibitors (First-Line Therapy)

Lisinopril is preferred as it is non-dialyzable 1:

• Initial dose: 2.5 mg once daily for hemodialysis patients 3
• Titrate up to maximum 40 mg once daily as tolerated 3
• Administer after dialysis on dialysis days 3

Fosinopril is non-dialyzable and preferred 1:

• 10-40 mg once daily 1
• No dose adjustment needed for dialysis 1

Benazepril is non-dialyzable 1:

• 10-40 mg once daily 1
• Preferred over enalapril or ramipril which are dialyzable 1, 4

Angiotensin Receptor Blockers (First-Line Alternative)

Telmisartan (non-dialyzable) 1, 4:

• 20-80 mg once daily 1
• May be more potent than ACE inhibitors for reducing left ventricular hypertrophy 2

Beta-Blockers (For Coronary Disease or Heart Failure)

Carvedilol is preferred as it is non-dialyzable 1, 4:

• Initial: 3.125-6.25 mg twice daily
• Target: 25-50 mg twice daily 1
• Superior to metoprolol for glycemic control and reducing new-onset microalbuminuria 1

Metoprolol succinate (extended-release):

• 50-200 mg once daily 1
• Metoprolol tartrate is dialyzable; succinate formulation preferred 1

Calcium Channel Blockers (Second-Line or Add-On)

Amlodipine (non-dialyzable) 1, 4:

• 2.5-10 mg once daily 1
• Reduces cardiovascular events in hemodialysis patients 2

Nifedipine LA (non-dialyzable) 1:

• 30-90 mg once daily 1

Cilnidipine:

• 10-20 mg once daily (standard dosing, no specific dialysis adjustment in guidelines)

Loop Diuretics (For Residual Renal Function Only)

Furosemide (if residual urine output >200 mL/day):

• 20-80 mg twice daily 1
• Ineffective without residual renal function 4

Torsemide (if residual urine output present):

• 5-10 mg once daily 1
• Preferred over furosemide for consistent absorption 1

Vasodilators (For Resistant Hypertension)

Hydralazine:

• 25-100 mg 2-3 times daily
• Used in combination regimens for resistant hypertension 1

Isosorbide dinitrate:

• 10-40 mg 2-3 times daily 5
• Must provide 14-hour dose-free interval to prevent tolerance 5
• Typically dosed at 8 AM and 2 PM, avoiding evening dose 5

Clonidine (non-dialyzable) 1, 4:

• 0.1-0.3 mg twice daily
• Preferred over methyldopa which is dialyzable 1

Minoxidil (non-dialyzable) 1:

• 2.5-10 mg once or twice daily
• Reserved for severe resistant hypertension after failure of triple therapy 1
• Requires concurrent beta-blocker and loop diuretic to prevent reflex tachycardia and fluid retention 1

Critical Implementation Considerations

Dialyzability matters: Avoid enalapril, ramipril, methyldopa, and atenolol as they are removed during dialysis, causing paradoxical blood pressure rises 1, 4. Prefer benazepril, fosinopril, clonidine, carvedilol, and calcium channel blockers which are non-dialyzable 1, 4.

Potassium monitoring is mandatory: Check potassium within 3-7 days of starting or titrating ACE inhibitors or ARBs, targeting 4.0-5.0 mEq/L 4. Hyperkalemia risk increases significantly in dialysis patients 1, 4.

Resistant hypertension algorithm (BP >140/90 mmHg despite adherence) 1:

1. Confirm dry weight achievement and sodium restriction
2. Ensure triple therapy with ACE inhibitor/ARB + calcium channel blocker + beta-blocker at near-maximal doses
3. Add hydralazine or minoxidil
4. If still uncontrolled, evaluate for secondary causes
5. Consider switch to peritoneal dialysis or bilateral nephrectomy as last resort 1

Avoid combination therapy: Never combine ACE inhibitors with ARBs due to increased hyperkalemia and acute kidney injury without cardiovascular benefit 4. Do not use direct renin inhibitors (aliskiren) in dialysis patients 4.

Timing of administration: Give medications after dialysis on dialysis days to avoid removal and ensure consistent levels 1, 3. Non-dialyzable agents provide more stable blood pressure control 4.