Antihypertensive drug use

Despite the controversies regarding BP measurement and optimal BP targets for HD patients, the use of antihypertensive medications in these patients does seem to confer benefits.  A meta-analysis of eight randomized clinical trials in 1,679 patients on dialysis (including some patients on peritoneal dialysis) demonstrated that active antihypertensive treatment significantly reduced the risk of cardiovascular events, all-cause mortality, and cardiovascular mortality by 29%, 20%, and 29%, respectively, compared with controls.19

The eight trials included in the meta-analysis used a variety of antihypertensive medication classes, including beta-blockers, ACE inhibitors, angiotensin receptor blockers and calcium channel blockers, but none was compared head-to-head.  Thus, recommendations regarding the preferential use of specific drug classes remain largely based on extrapolation from non-dialysis populations (e.g., beta-blockers following a myocardial infarction). 

Of note, in the recent Hypertension in Hemodialysis Patients Treated with Atenolol or Lisinopril (HDPAL) study,20 HD patients with left ventricular hypertrophy and hypertension randomized to an atenolol-based regimen had lower rates of heart failure and other cardiovascular events compared with patients receiving a lisinopril-based regimen. However, this was a relatively small study (200 patients) with predominately African-American patients (86%), necessitating replication of this trial in larger, more diverse dialysis populations.


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In summary, there are a number of controversies regarding BP management in HD patients, including the optimal method of measurement, appropriate and safe BP targets, and whether certain classes of antihypertensive medications are preferred over others.

Despite these ongoing uncertainties, controlling BP to a level of less than 140/90 mm Hg pre-dialysis using a combination of pharmacologic and non-pharmacologic therapies (e.g., maximizing ultrafiltration, reducing sodium exposure in the diet and dialysate, and extending the duration and frequency of HD), without precipitating intradialytic hypotension, is a reasonable goal.  Future studies that will put these controversies to rest are clearly needed. 

Dr. Chang is an instructor in medicine (nephrology) at the Stanford University School of Medicine in Palo Alto, Calif.


References

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