What is the choice of antihypertensive drug in a hypertensive emergency in a patient with End-Stage Renal Disease (ESRD)?

From the Guidelines

In hypertensive emergencies in patients with end-stage renal disease (ESRD), intravenous nicardipine, clevidipine, or labetalol are preferred first-line agents. Nicardipine (initial dose 5 mg/hr, titrated by 2.5 mg/hr every 5-15 minutes, maximum 15 mg/hr) offers effective blood pressure control with minimal dosage adjustment needed in ESRD, as noted in the 2018 guideline for the prevention, detection, evaluation, and management of high blood pressure in adults 1. Clevidipine (starting at 1-2 mg/hr, titrated by doubling the dose every 90 seconds until desired BP, maximum 32 mg/hr) provides rapid onset and offset with minimal renal impact, making it a suitable option for patients with ESRD 1. Labetalol (initial 20 mg IV bolus, followed by 20-80 mg every 10 minutes or 1-2 mg/min infusion) combines alpha and beta blockade but requires caution in patients with bradycardia or heart failure, as highlighted in 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 1.

Some key points to consider when choosing an antihypertensive agent in ESRD patients include:

• Avoiding nitroprusside due to thiocyanate accumulation risks, as mentioned in the European Heart Journal study 1
• Transitioning to oral medications like amlodipine, metoprolol, or hydralazine once stabilized, adjusting for dialysis considerations, as recommended in the Journal of the American College of Cardiology guideline 1
• Gradually reducing blood pressure (about 25% reduction in first hour, then to 160/100 mmHg within next 2-6 hours) to prevent organ hypoperfusion, as suggested in the Circulation guideline 1
• Considering the altered pharmacokinetics and hemodynamic challenges specific to ESRD patients, including volume overload, electrolyte imbalances, and altered drug clearance, as discussed in the Journal of the American College of Cardiology study 1.

Overall, the choice of antihypertensive agent in ESRD patients should be guided by the need to effectively lower blood pressure while minimizing the risk of adverse effects and accommodating the unique challenges of ESRD, as emphasized in the Hypertension guideline 1.

From the FDA Drug Label

DOSAGE AND ADMINISTRATION DOSAGE MUST BE INDIVIDUALIZED. The recommended initial dosage is 100 mg twice daily whether used alone or added to a diuretic regimen. The FDA drug label does not answer the question.

From the Research

Antihypertensive Drug Options

• Sodium nitroprusside, nitroglycerin, and hydralazine have been used for many years as first-line options for patients with hypertensive emergencies, although their potential adverse effects and difficulties in use were well known 2.
• Equally potent and less toxic alternatives, including nicardipine, fenoldopam, labetalol, and esmolol, are increasingly used worldwide 2.
• Clevidipine, a third-generation dihydropyridine calcium-channel blocker, was shown in clinical trials to reduce mortality when compared with nitroprusside 2.

Selection of Antihypertensive Agents

• The selection of a specific agent should be based on the agent's pharmacology and patient-specific factors, such as comorbidity and the presence of end-organ damage 3.
• In patients with end-stage renal disease (ESRD), the choice of antihypertensive agent may need to consider the patient's renal function and potential electrolyte imbalances.
• However, there is limited information available on the specific choice of antihypertensive drug in hypertensive emergency in ESRD.

Treatment Approach

• Rapid controlled reduction of blood pressure may be necessary to prevent or minimize end-organ damage in patients with hypertensive emergencies 3.
• The treatment approach should be individualized, taking into account the patient's underlying medical conditions, such as ESRD, and the presence of any acute organ injury 4.
• In general, oral agents should not be used for the treatment of hypertensive emergencies, and intravenous agents such as labetalol and nicardipine may be used in specific situations 5.

Considerations in ESRD

• Patients with ESRD may require closer monitoring of their blood pressure and electrolyte levels during treatment of hypertensive emergencies.
• The choice of antihypertensive agent in ESRD should consider the potential effects on renal function and electrolyte balance.
• However, there is no specific guidance available on the choice of antihypertensive drug in hypertensive emergency in ESRD, and the treatment approach should be individualized based on the patient's specific needs and medical conditions 3, 4.