Is nitroglycerine or furosemide (Lasix) more effective for managing hypertension (HTN) in a patient with end-stage renal disease (ESRD) on dialysis and anuria?

From the Guidelines

For a patient with anuric end-stage renal disease (ESRD) on dialysis experiencing hypertension, nitroglycerin is generally preferred over furosemide (Lasix). Nitroglycerin works as a vasodilator, relaxing blood vessels and reducing blood pressure without depending on kidney function for its effect or elimination, as noted in the study by 1. The typical approach would be to use nitroglycerin patches (0.2-0.4 mg/hr) or sublingual tablets (0.3-0.6 mg) as needed for acute management.

Key Considerations

• Furosemide is largely ineffective in anuric ESRD patients because it requires functioning kidneys to produce its diuretic effect, as highlighted by the guidelines in 1.
• Since these patients produce no urine, the medication cannot work through its primary mechanism of action.
• Fluid overload in dialysis patients is better managed through the dialysis process itself rather than attempting diuresis with medications.
• Other antihypertensives that may be more appropriate for long-term management in these patients include calcium channel blockers like amlodipine (5-10 mg daily) or beta-blockers like metoprolol (25-100 mg twice daily), as they don't rely on renal function for their blood pressure-lowering effects.

Management Approach

• The choice of initial pharmacological therapy for hypertension in dialysis patients should consider the lack of renal function and the potential for certain medications to exacerbate conditions such as fluid overload.
• Monitoring for potential adverse effects of nitroglycerin, such as profound hypotension, is crucial, especially in vulnerable populations like the elderly or those who are volume depleted, as discussed in 1.
• The use of diuretics in patients on hemodialysis (HD) cannot be recommended for blood pressure control unless there is substantial residual kidney function, according to the guidelines in 1.

From the Research

Hypertension Management in ESRD Patients

• Hypertension is a common comorbidity in end-stage renal disease (ESRD) patients, with a prevalence of over 85% 2.
• The management of hypertension in ESRD patients is complex and requires individualized therapy, taking into account patient comorbidities and the potential for medication removal with dialysis 3, 4.

Antihypertensive Medications

• Angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), and beta-blockers are reasonable first-line agents for most ESRD patients 3, 5.
• Beta-blockers may be considered as a first-line therapy in dialysis patients, as they can reduce sympathetic overactivity and left ventricular hypertrophy 6.
• Mineralocorticoid receptor antagonists have also reported promising results in reducing mortality in dialysis patients, but safety issues such as hyperkalemia or hypotension need to be evaluated further 6.

Volume Control and Dialysis

• Maintaining euvolemia is crucial for blood pressure control in dialysis patients 6.
• Intensive hemodialysis has been shown to reduce blood pressure and the need for antihypertensive medications 2.

Specific Medications - Nitroglycerine and Lasix

• There is no direct comparison between nitroglycerine and Lasix (furosemide) in the management of hypertension in anuric ESRD patients on dialysis in the provided studies.
• Furosemide is a diuretic, which may not be effective in anuric patients, as they have minimal urine output 5.
• Nitroglycerine is a vasodilator, which can be used to manage hypertension, but its use in ESRD patients on dialysis is not specifically addressed in the provided studies.