Pharmacokinetics Class Half-life Range of dosing % removal by HD Atenolol < 120 h 25-50 mg q 48 h 75% Metoprolol 3-8 h 50-200 mg bid High Propanolol 3-6 h 40-120 mg q bid < 5% Carvedilol 7-10 h 6.25-25 mg q bid None Bisoprolol 10-12 h None 2.5-10 mg qd Inrig JK, et al. Semin Dial. 2010;23(3):290-297
Pharmacokinetics Class Half-life Range of dosing % removal by HD Amlodipine 50 h 2.5-10 mg qd None Diltiazem < 30% Nifedipine Prolonged Varies with formulation Low Felodipine 5h 30-180 mg qd None Verapamil 11-16 2.5-10 mg qd Low Manidipine None Prolonged Varies with formulation 4-8 h 10-20 mg qd Inrig JK, et al. Semin Dial. 2010;23(3):290-297
Pharmacokinetics Class Half-life Range of dosing % removal by HD Doxazocin 15-22 h 1-8 mg hs None Prazocin 2-4 h None Methyldopa 1.8-2 h 1-5 mg bid to tid 60% 125-250 mg qd-bid Hydralazine 7-16 h 10-100 mg q 8 h None ? 5-100 mg q 8h Partially Minoxidil ? 5-100 mg tid Yes Isosorbide dinitrate 80-160 mg q 24 h Inrig JK, et al. Semin Dial. 2010;23(3):290-297
Intradialytic Hypertension Potential Strategy Potential methods Reduce volume overload Increase ultrafiltration Control electrolyte change Reduce cardiac output Reduce sympathetic Restrict dietary salt overactivity Intradialytic sodium balance Inhibit RAAS Reduce dialysate calcium concentration Evaluate concurrent therapy Prescribe ACEi or ARBs Adminiter adrenergic receptor blockers ( alpha- /beta-blocker) Daily dialysis Increase duration of dialysis Prescribe ACEi or ARBs Drug compliance Drugs which might being removed by dialysis
Withholding antihypertensives prior to dialysis routinely in patients may • worsen interdialytic blood pressure control • increase the prevalence of euvolemic ID-HTN. • increase the risk of cardiac arrhythmias • compromise hemodynamic stability during dialysis. Krishnan N. Sem Dial 2016: 29(4):323-325
Chang T. Kidney 360. 2021;2:1752-1760
Management of Intradialytic Hypertension • Avoid skipping anti-hypertensive medications • Prescribe medications in daily evening dose • Choose non-dialyzable anti-hypertensive drugs which inhibit RAAS
Carvedilol on CV Mortality Cice et al. JACC 2003: 41: 1438-1444.
Q4 How do you manage hypertension in this patient? 1. Taking medications in the evening 2. Reduce dry weight 3. Reduce dose of erythropoietin 4. Increase metoprolol twice daily
Topics 1. Prevalence of HT 1. 70-80% 2. Methods using to 2. ABPM-gold standard determine BP Best correlation: Home BP 3. Diagnosis of HT 3. Home BP > 135/85 mmHg 4. Pathophysiology 4. Volume overload 5. Management 5. Non-phramacology vs. pharmacology
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