Special considerations for antihypertensive agents in dialysis patients

Hypertension is present in most patients with end-stage renal disease and likely contributes to the premature cardiovascular disease in dialysis patients. Previous practice guidelines have recommended that, in patients on chronic dialysis, blood pressure (BP) should be reduced below 130/80 mm Hg. This is based on opinions but not strong evidence, since no concrete information exists about which BP values should be the parameter to follow and which should be the target BP values. The majority of the antihypertensive agents can be used in this population, but the pharmacokinetics altered by the impaired kidney function and dialyzability influence the appropriate dosage as well as the time and frequency of administration. Combination therapy using multiple agents is often necessary. Because of the prevalence of overactivity of the renin-angiotensin-aldosterone system and sympathetic tone as well as the high calcium influx in vascular smooth muscle cells in dialysis patients, drugs acting in these three specific systems may potentially have additional cardioprotective benefits beyond their BP-lowering effect. Thus, antihypertensive regimens should preferably be based on these classes of drugs, alone or in combination. Other antihypertensive drug classes can play a complementary role.