From the Guidelines
For this patient with ESRD on dialysis experiencing hypertensive emergency despite multiple antihypertensives, I recommend optimizing the medication regimen by first increasing the Entresto to 97-103 mg twice daily if tolerated, as suggested by the 2020 international society of hypertension global hypertension practice guidelines 1. This approach is supported by the guidelines, which emphasize the importance of optimizing the current treatment regimen, including health behavior change and diuretic-based treatment, to achieve blood pressure targets. Additionally, consider adding a long-acting calcium channel blocker like amlodipine 10 mg daily instead of nifedipine, which may provide more consistent blood pressure control, as calcium channel blockers are recommended for patients with chronic kidney disease 2. The clevidipine drip should be continued until oral medications achieve better control, with a gradual taper as BP improves. Since the patient has already undergone ultrafiltration with 7L removal during dialysis but remains hypertensive, volume overload may not be the primary issue, and the KDIGO conference on blood pressure and volume management in dialysis highlights the importance of individualizing the dialysis prescription and considering multiple clinical factors and risk considerations 3. Consider consulting nephrology to evaluate for secondary causes of resistant hypertension such as renal artery stenosis, hyperaldosteronism, or inadequate dialysis, as recommended by the 2020 international society of hypertension global hypertension practice guidelines 1. The patient's current regimen includes medications from different classes (ARNI, beta-blocker, diuretic, calcium channel blocker), but ESRD patients often require 4-5 agents for adequate control, and adding a central-acting agent like clonidine 0.1-0.2 mg twice daily or minoxidil 5-10 mg daily might help, as supported by 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 2. Monitor for orthostatic hypotension and adjust dry weight goals during dialysis if needed, and home blood pressure monitoring between dialysis sessions would provide valuable information for medication adjustments. Key considerations in managing this patient's blood pressure include:
- Optimizing the medication regimen to achieve blood pressure targets
- Evaluating for secondary causes of resistant hypertension
- Individualizing the dialysis prescription to address volume overload and other clinical factors
- Monitoring for orthostatic hypotension and adjusting dry weight goals as needed
- Using home blood pressure monitoring to inform medication adjustments.
From the Research
Management of Hypertension in ESRD Patient
The patient has a history of End-Stage Renal Disease (ESRD) and is on dialysis, presenting with a hypertensive emergency. The current management includes a cleviprex drip, and the patient is also on entresto, carvedilol, furosemide, and nifedipine. Despite these efforts, the blood pressure remains elevated at 180-195/96-104 mmHg.
Current Medications and Their Effects
- Cleviprex (clevidipine) is a calcium channel blocker used for acute hypertension management, as discussed in 4.
- Entresto (sacubitril/valsartan) is an angiotensin receptor-neprilysin inhibitor used for heart failure and hypertension.
- Carvedilol is a beta-blocker used for hypertension and heart failure.
- Furosemide is a diuretic used for fluid overload, which can contribute to hypertension in ESRD patients.
- Nifedipine is a calcium channel blocker used for hypertension.
Blood Pressure Goals
According to 5, the general recommendation is to lower systolic blood pressure to below 140 mmHg in all hypertensive patients. However, for patients with diabetes or high/very-high-risk patients, the goal is to achieve systolic blood pressure levels below 130 mmHg. In the context of ESRD, managing fluid overload and using antihypertensive medications judiciously is crucial, as noted in 6.
Adjusting Current Management
Given the patient's elevated blood pressure despite current management, several options could be considered:
- Adjusting the dose of cleviprex, as its effectiveness in acute hypertension is well-documented 4, 7.
- Optimizing the doses of entresto, carvedilol, and nifedipine, considering the patient's response and potential side effects.
- Ensuring adequate fluid management through dialysis and diuretics like furosemide, as fluid overload is a common issue in ESRD patients that can exacerbate hypertension.
Considerations for ESRD Patients
For patients with ESRD, the management of hypertension must balance the need to control blood pressure with the potential for exacerbating renal dysfunction or causing other adverse effects. Guidelines for managing hypertension in these patients emphasize the importance of individualized care, considering factors such as the presence of diabetes, proteinuria, and the degree of renal impairment, as discussed in 6 and 8.