Hypertension affects most hemodialysis patients and is often poorly controlled. Adequate control of blood pressure is difficult with conventional hemodialysis alone but is important to improve cardiovascular outcomes. Nonpharmacologic interventions to improve blood pressure include educating patients about limiting sodium intake, ensuring adequate sodium solute removal during hemodialysis, and achieving target “dry weight.” However, most patients require a number of antihypertensive medications to achieve an appropriate blood pressure. First-line antihypertensive agents include angiotensin converting enzyme inhibitors and angiotensin receptor blockers given their safety profile and demonstrated benefit on cardiovascular outcomes in clinical trials. β-blockers and combined α- and β-blockers should also be used in patients with cardiovascular disease or congestive heart failure and may improve outcomes in these populations. Calcium channel blockers and direct vasodilators are also effective for controling blood pressure. Many blood pressure agents can be dosed once daily and should preferentially be administered at night to control nocturnal blood pressure and minimize intradialytic hypotension. In patients who are noncompliant with therapy, renally eliminated agents (such as lisinopril and atenolol) can be given thrice weekly following hemodialysis. Older antihypertensive agents which require thrice daily dosing ought to be avoided given the high pill burden with these regimens and the concern for noncompliance resulting in rebound hypertension. Newer antihypertensive agents, such as direct renin inhibitors, may provide alternative options to improve blood pressure but require testing for efficacy and safety in hemodialysis patients.
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