-Dialysis will help with BP control when the patient achieves optimal dry weight.
1. Beta-blockers (1st line)
–Atenolol 25-100 mg PO three times per WEEK. Start with 25 mg three times per week and titrate up.
Atenolol can be dialyzed off.
2. Dihydropyridine Calcium Channel Blockers (2nd line). If the Beta-blocker alone does not work, you add a CCB.
—Amlodipine 5-10 mg PO daily
3. ACE-I or ARB (3rd choice) – see below for some concerns about ACE-I/ARBs.
–Lisinopril 10-20 mg PO
Resistant Hypertension
Look for a secondary cause of HTN: Review drugs (for meds that may raise BP, e.g. NSAIDs), noncompliance with medications, renovascular hypertension, and expanding cyst size in polycystic kidney disease. ***Noncompliance is a common cause of persistent hypertension.
Drugs to consider
- Minoxidil
- Guanfacine
- Clonidine — central sympathetic agonist that is used less frequently because of CNS side-effects.
- Methyldopa–central sympathetic agonist that is used less frequently because of CNS side-effects.
- Spironolactone –studies have shown it works, however, it’s best to avoid because of the risk of hyperkalemia.
** For noncompliant patients, consider giving long-acting BP meds at the dialysis center. E.g.
ACE / ARB in dialysis patients
***There is some concern that ACE and ARBs may not be as effective in dialysis patients. However, many nephrologists still use them.
Some studies show that atenolol is safer and better than ACE-I / ARBs.
They are particularly effective in patients who have HFrEF (i.e. HF due to systolic dysfunction) or have had an acute MI.
If you do use ACE-I/ARB, monitor potassium levels carefully!
ACE inhibitors may interfere with the action of erythropoietin-stimulating agents (ESAs) and increase the risk of hyperkalemia
https://www.ncbi.nlm.nih.gov/pubmed/25877881