Antihypertensive Agents in the Dialysis Patient
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Purpose of Review
Hypertension and antihypertensive drug utilization are remarkably prevalent in ESRD patients. Management of blood pressure elevation in this population is complicated by many factors, including a multidimensional etiology, challenges in obtaining accurate and appropriately timed blood pressure measurements, highly specific drug dosing requirements, and a paucity of outcomes-based evidence to guide management decisions. The purpose of this review is to summarize and apply knowledge from existing clinical trials to enhance safe and effective use of antihypertensive agents in dialysis patients.
Two meta-analyses have established the benefit of antihypertensive therapy in ESRD. Data supporting the use of one antihypertensive class over another is less robust; however, beta-blockers have more clearly demonstrated improved cardiovascular outcomes in prospective randomized trials. Interdialytic home blood pressure monitoring has been demonstrated to be better associated with cardiovascular outcomes than clinic pre- or post-dialysis readings and should ideally be considered as a routine part of blood pressure management in this population.
As data from small trials provides limited guidance for the management of hypertension in ESRD, more research is needed to guide medication selection and utilization. Specifically, large prospective randomized trails comparing cardiovascular outcomes of various medication classes and differing blood pressure targets are needed.
KeywordsHypertension Hemodialysis Chronic kidney disease Antihypertensive agents
Compliance with Ethical Standards
Conflict of Interest
The authors declare that they have no conflict of interest.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
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- 3.Sarafidis PA, Mallamaci F, Loutradis C, Ekart R, Torino C, Karpetas A, et al. Prevalence and control of hypertension by 48-h ambulatory blood pressure monitoring in haemodialysis patients: a study by the European Cardiovascular and Renal Medicine (EURECA-m) working group of the ERA-EDTA. Nephrol Dial Transplant. 2018. https://doi.org/10.1093/ndt/gfy147.
- 4.Centers for Disease Control and Prevention. National Chronic Kidney Disease Fact Sheet, 2017. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention; 2017.Google Scholar
- 12.• Sarafidis P, Persub A, Agarwal R, Burnierf M, de Leeuwg P, Ferroi C, et al. Hypertension in dialysis patients: a consensus document by the European Renal and Cardiovascular Medicine (EURECA-m) working group of the European Renal Association ^ European Dialysis and Transplant Association (ERA-EDTA) and the hypertension and the kidney working group of the European Society of Hypertension (ESH). J Hypertens. 2017;35:657–76 This position paper is a comprehensive review of management of hypertension in dialysis, including etiology, blood pressure measurement, suggested blood pressure targets, utilization of antihypertensive agents, recommended first and second-line therapies, and opportunities for future research.CrossRefGoogle Scholar
- 17.• Levin NW, Kotanko P, Eckardt K, Kasiske BL, Chazot C, Cheung A, et al. Blood pressure in chronic kidney disease stage 5D – report from a kidney disease: improving global outcomes controversies conference. Kidney Int. 2010;77(4):273–84. https://doi.org/10.1038/ki.2009.469 This position paper is a comprehensive review of management of hypertension in dialysis, including etiology, blood pressure measurement, utilization of antihypertensive agents, and opportunities for future research.CrossRefPubMedGoogle Scholar
- 25.•• Alborzi P, Patel N, Agarwal R. Home blood pressures are of greater prognostic value than hemodialysis unit recordings. Clin J Am Soc Nephrol. 2007;2:1228–34 This prospective trial helped to establish the utility of home blood pressure measurement as an accurate means for monitoring blood pressure in ESRD based on correlation with cardiovascular outcomes.CrossRefGoogle Scholar
- 29.•• Heerspink HJ, Ninomiya T, Zoungas S, de Zeeuw D, Grobbee DE, Jardine MJ, et al. Effect of lowering blood pressure on cardiovascular events and mortality in patients on dialysis: a systematic review and meta-analysis of randomised controlled trials. Lancet. 2009;373:1009–15 This meta-analysis, including nine clinical trials, was the first of its kind published to establish the cardiovascular benefit of antihypertensive agents in ESRD patients.CrossRefGoogle Scholar
- 30.•• Agarwal R, Sinha AD. Cardiovascular protection with antihypertensive drugs in dialysis patients: systematic review and meta-analysis. Hypertension. 2009;53:860–6 This meta-analysis, including five clinical trials, helped to confirm the cardiovascular benefit of antihypertensive agents in ESRD patients and highlighted potentially greater benefit in dialysis patients with hypertension specifically.CrossRefGoogle Scholar
- 33.Baigent C, Landray MJ, Reith C, Emberson J, Wheeler DC, Tomson C, et al. The effects of lowering LDL cholesterol with simvastatin plus ezetimibe in patients with chronic kidney disease (Study of Heart and Renal Protection): a randomised placebo-controlled trial. Lancet. 2011;377:2181–92.CrossRefGoogle Scholar
- 34.Mallappallil M, Fishbane S, Wanchoo R, Lerma E, Roche-Recinos A, Salifu M. Practice patterns in transitioning patients from chronic kidney disease to dialysis: a survey of United States nephrologists. BMC Nephrol 2018:19. https://doi.org/10.1186/s12882-018-0943-0.
- 35.Whelton PK, Carey RM, Aronow WS, et al. 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: Executive Summary: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension. 2017;71(6):1269–324. https://doi.org/10.1161/hyp.0000000000000066.CrossRefPubMedGoogle Scholar
- 36.Aronoff GR. Drug prescribing in renal failure: dosing guidelines for adults and children. 5th ed. Philadelphia: American College of Physicians; 2009.Google Scholar
- 37.Mallamaci F, Zoccali C. Hypertension. In: Daugirdas JT, Blake PG, Ing TS, editors. Handbook of dialysis. 5th ed. Philadelphia: Lippincott Williams & Wilkins; 2015.Google Scholar
- 39.•• Cice G, Ferrara L, D’Andrea A, D’Isa S, Di Benedetto A, Cittadini A, et al. Carvedilol increases two-year survival in dialysis patients with dilated cardiomyopathy: a prospective, placebo controlled trial. J Am Coll Cardiol. 2003;41:1438–44 This is one of very few prospective, randomized controlled, double blind studies examining antihypertensive agents in ESRD to find clinically and statistically significant benefit with treatment.CrossRefGoogle Scholar
- 43.•• Tepel M, Hopfenmueller W, Scholze A, Maier A, Zidek W. Effect of amlodipine on cardiovascular events in hypertensive haemodialysis patients. Nephrol Dial Transplant. 2008;23:3605–12 This is one of very few prospective, randomized controlled, double blind studies examining antihypertensive agents in ESRD; clinically and statistically significant benefit with treatment was found.CrossRefGoogle Scholar