Antihypertensive Management in ESRD Patients on Dialysis

Initial Management Approach

The American Journal of Kidney Diseases recommends achievement of dry weight through ultrafiltration and dietary sodium restriction as the cornerstone of blood pressure management in dialysis patients 1, 2
Target predialysis blood pressure should be 140/90 mmHg (measured in sitting position) 1, 2
Lifestyle modifications including salt restriction should be continuously emphasized 1

ACE inhibitors or ARBs are recommended as first-line agents for most dialysis patients 1, 3
These agents reduce left ventricular hypertrophy in hemodialysis patients 1
ACE inhibitors have been associated with decreased mortality in observational studies of ESRD patients 1
ARBs may be more potent than ACE inhibitors for LVH reduction 1

For patients with previous myocardial infarction or established coronary artery disease, beta-blockers should be preferred 1, 3
Beta-blockers are associated with decreased mortality in CKD patients 1
Calcium channel blockers (CCBs) should be considered as part of the regimen when additional agents are needed 1, 3
Observational studies suggest CCBs are associated with decreased total and cardiovascular mortality in dialysis patients 1, 3
For patients with residual kidney function (RKF), ACE inhibitors or ARBs are particularly beneficial 4, 5, 6
These agents slow the decline in residual kidney function in peritoneal dialysis patients 5, 6

Consider the dialyzability of medications when selecting agents 3, 7
Hemodialysis reduces blood levels of some ACE inhibitors (enalapril, ramipril) but not others (benazepril, fosinopril) 3, 7
Levels of clonidine, carvedilol, labetalol, CCBs, and ARBs do not change significantly during dialysis 3, 7

Resistant hypertension is defined as BP >140/90 mmHg despite achieving dry weight and using three appropriate antihypertensive agents 1, 3
If BP remains uncontrolled with three agents, evaluate for secondary causes of resistant hypertension 1, 3
For severe resistant hypertension, consider adding minoxidil as a potent vasodilator 1, 3
If hypertension remains uncontrolled after a trial with minoxidil, consider switching to peritoneal dialysis 1, 3
If peritoneal dialysis proves ineffective, surgical or embolic nephrectomy may be considered 1, 3

Avoid using ACE inhibitors in patients treated with polyacrylonitrile dialysis membranes due to risk of anaphylactoid reactions 8
Be cautious with aggressive BP lowering in elderly patients with isolated systolic hypertension 1, 3
Paradoxical rise in blood pressure can occur during dialysis due to removal of certain antihypertensive drugs or excessive volume depletion 3, 7