I have a patient 71 years old ,CKD on regular hemodialysis 2 years ago , ischemic heart disease ,hypertensive , diabetic , with a history of previous CABG 2 years ago . The patient is schedulled for dialysis 2 times per week , 4hours each.
The patient suffers from uncontrolled hypertension . he takes metoprolol 100 mg in 2 divided doses , amilodipine 5 mg ( he complains of lower limb edema when he increased the dose ), alpha methyl dopa 250 mg 2 times / day .Actually his BP pre dialysis reaches 180 / 100 despite not being overloaded . The patient respond rapidly to sublingual nitrates as it reaches 130 / 70 , but again it rises through the session despite controlling sodium level on the machine .
I added ARBS in the form of Micardis 40 mg once / day , but still the patient BP is uncontrolled.