From the FDA Drug Label
The RENAAL study was a randomized, placebo-controlled, double-blind, multicenter study conducted worldwide in 1513 patients with type 2 diabetes with nephropathy (defined as serum creatinine 1.3 to 3.0 mg/dL in females or males ≤60 kg and 1.5 to 3. 0 mg/dL in males >60 kg and proteinuria [urinary albumin to creatinine ratio ≥300 mg/g]). Treatment with losartan resulted in a 16% risk reduction in this endpoint (see Figure 4 and Table 4) Treatment with losartan also reduced the occurrence of sustained doubling of serum creatinine by 25% and ESRD by 29% as separate endpoints, but had no effect on overall mortality (see Table 4).
The best blood pressure lowering medicine for someone on dialysis is losartan, as it has been shown to reduce the risk of doubling of serum creatinine, end-stage renal disease (ESRD), and death in patients with type 2 diabetes and nephropathy 1.
- Key benefits of losartan include:
- Reduced risk of doubling of serum creatinine by 25%
- Reduced risk of ESRD by 29%
- Reduced proteinuria by an average of 34%
- Reduced rate of decline in glomerular filtration rate by 13% However, it is essential to note that losartan had no effect on overall mortality in the RENAAL study 1.
From the Research
The best blood pressure lowering medicine for someone on dialysis is typically a calcium channel blocker such as amlodipine (5-10 mg daily). This is because calcium channel blockers remain effective regardless of kidney function and have minimal dialysis clearance, making them a preferred choice for patients on dialysis 2.
Key Considerations
- For patients who need additional blood pressure control, ACE inhibitors or ARBs like lisinopril (2.5-10 mg daily) or losartan (25-50 mg daily) may be added, though these require careful monitoring for hyperkalemia and should be given after dialysis on treatment days 3, 4.
- Beta-blockers such as metoprolol (25-100 mg twice daily) are also commonly used, especially for patients with heart failure or coronary artery disease 2.
- Dialysis patients often require multiple medications for adequate blood pressure control due to their complex cardiovascular status and fluid balance issues.
- Blood pressure medications should be timed appropriately around dialysis sessions, with most medications taken after dialysis to prevent removal during treatment.
Monitoring and Adjustments
- Regular monitoring of blood pressure both before and after dialysis sessions is essential to adjust medication dosing appropriately and achieve target blood pressure goals 2.
- Serum potassium concentration should be closely monitored when ACE inhibitors or ARBs are prescribed for hemodialysis patients to prevent hyperkalemia 3, 5.
Recent Guidance
- A recent review highlights the importance of managing potassium and renal function when using ACE inhibitors and ARBs, which is particularly relevant for patients on dialysis 5.