Background: Blood pressure (BP)-lowering with the use of antihypertensive drugs appears to
protect the cardiovascular (CV) system in hemodialysis patients. However, the optimal treatment algorithm
of hypertension remains elusive; extrapolation of clinical-trial evidence from the general population
may not be optimal.
Methods: For this narrative review, we searched the Medline/PubMed database (inception to August 01,
2019) to identify randomized clinical trials evaluating the efficacy of antihypertensive drugs on CV
outcomes and mortality in patients on hemodialysis.
Results: Randomized trials with angiotensin-converting-enzyme-inhibitors (ACEIs) or angiotensinreceptor-
blockers (ARBs) failed to provide consistent cardioprotection. β-blockers may provide a more
consistent CV benefit. Although some early clinical trials have shown that mineralocorticoid-receptorantagonists
(MRAs) reduce CV mortality, the associated risk of hyperkalemia raises important safety
concerns on the use of MRAs as add-on therapy.
Conclusion: Our first-line therapy of hypertension in hemodialysis is the assessment and management
of dry-weight and optimization of dialysis prescription. Based on the available clinical-trial evidence,
we prescribe atenolol 3 times/week after dialysis as the first-line pharmacological option of hypertension
to our patients without specific indications for other agents. Long-acting dihydropyridines and
ACEIs/ARBs are our second-line and third-line choices, respectively. We avoid using MRAs and await
results from ongoing trials testing their safety and efficacy. In patients receiving maintenance hemodialysis,
randomized trials are clearly warranted in order to define BP targets and the comparative effectiveness
of different antihypertensive drugs.