Antihypertensive drugs in patients on dialysis and those with CKD not on dialysis

Which antihypertensive drugs are preferred in patients treated with hemodialysis and which in those with chronic kidney disease in whom hemodialysis is not yet indicated?

Ally Prebtani, MD: In those on hemodialysis there is very little evidence, so you can probably pick any of the agents—except for diuretics, which probably do not work. So angiotensin-converting enzyme (ACE) inhibition, angiotensin-receptor blockers (ARBs), dihydropyridine calcium channel blockers, and if the patients are young, beta-blockers may also be considered. Thiazide or thiazide-like diuretics probably do not work as well because of the fact that the patients are on hemodialysis.

If they have chronic kidney disease and are not on hemodialysis, it depends on whether they have proteinuria. If they have proteinuria, then the preference would be for ACE inhibitors or ARBs as first-line therapy. If they do not have proteinuria, the preference is still for ACE inhibitors or ARBs but we have more options: You can consider also thiazide-like diuretics as long as your glomerular filtration rate (GFR) is >30 mL/min/1.73 m₂ or calcium channel blockers, and beta-blockers if the patients are younger.