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  Tuesday, 05 February 2013
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Dear Experts Case: HD patient with sys BP 180-200. no response to dry weight reduction (cant lower down, likely is at dry weight). On all classes of BP reduction meds (reasonable dose,  ACEinh, BB, long acting CCB, vasodilator and central alpha agonist). Has tried lower HD Na bath with no help. Should ARB be added to the regimen?  In regards to BP management in general, do we know how much better BP control we get if we add Aceinh to ARB or vice versa?  I understand we avoid this combination now because of recent concerns in CKD population. Would anybody look at renal artery stenosis in dialysis patients (cases of resistant HTN with no other usual causes)?
11 years ago

Some of these patients may have persistent renin production. You might try aliskiren in place of the ACE or ARB to see if this is playing a role. Recall that nephrectomy in ESRD was previously used to treat renin-mediated hypertension in such patients. This might be the medical equivalent. As for adding ACE to ARB (or vice versa) or Aliskiren to ARB or ACE, it would be very tenuous to translate the data from patients without ESRD to patients who do have it.

We had a nice response to the addition of small doses of spironolactone in two similar patients (yes, HD patients!), carefully monitoring potassium levels.

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