297the risk of hyperkalemia in these patients, potentially by inhibiting extrarenal potas-
sium loss. Therefore, monitoring of serum potassium after initiation of RAS inhibi-
tors is recommended [ 47 ]. ACEIs have also been associated with higher dose
requirements for erythropoietin-stimulating agents in HD [ 47 ].
Most ACEIs (with the exception of fosinopril) are removed by HD. This is not
problematic in most hypertensive patients and may help avoid intradialytic hypoten-
sion. However, in those who experience intradialytic hypertension, dialyzable
ACEIs should be switched to either fosinopril or an ARB [ 47 ].
The effects of ARBs on BP were variable in different studies. Some trials have
shown an association of ARBs with a reduction of cardiovascular events and mortal-
ity in dialysis patients [ 57 , 58 ], while others did not confirm this benefit [ 59 ].
ARBs can be administered once daily, they are not removed by HD, and they are
well tolerated in dialysis patients [ 47 ]. In two trials, the use of an ARB was not
associated with hyperkalemia or with higher erythropoietin requirements [ 57 , 58 ].
Diuretics
In 16,420 HD patients from the Dialysis Outcomes and Practice Patterns Study
(DOPPS) diuretic use was associated with lower interdialytic weight gain, lower
risk of hyperkalemia (>6.0 mmol/L), and higher odds of retaining residual renal
function after 1 year, as compared to patients not on diuretic therapy. Patients on
diuretics also had a 7% lower all-cause mortality risk (P = 0.12) and 14% lower
cardiac mortality risk (P = 0.03) than patients without diuretics [ 60 ].
Calcium Channel Blockers
CCBs can effectively lower BP in dialysis patients. They are not removed by HD
and, thus, do not require additional post-dialysis dosing [ 47 ]. A recent RCT found
that amlodipine lowered systolic BP by 10 mmHg more than placebo, without an
increased risk of intradialytic hypotension [ 61 ]. In an RCT comparing amlodipine
to placebo in 251 hypertensive HD patients, Tepel et al. [ 62 ] found no difference in
all-cause mortality at 30 months; however, amlodipine significantly reduced the
secondary combined endpoint of all-cause mortality and cardiovascular events.
Dual Blockade of the RAS
A small study [ 63 ] randomized 33 incident diabetic HD patients to an ACEI versus
ARB versus combination of ACEI + ARB and achieved good BP control and regres-
sion of LV mass index (LVMI) at 1 year in all groups. However, the patients treated
with the ACEI + ARB combination exhibited an additional 28% reduction in LVMI
18 Treatment of Hypertension in Light of the New Guidelines: Pharmacologic...