A maneuver to reduce the high pill burden and enhance the patients compliance is supervised thrice weekly administration of long-acting agents immediately postdialysis (59,60). the DRIP TrialProbing of dry weight145.8/82.9Week 4: ?10.7/?6.1; week 8: ?13.5/?7.2Agarwal (15)2014100HDHypertension with LVHAtenolol group of the HDPAL trialAtenolol (25C100 mg TIW postdialysis) plus dry weight reduction plus dialysate sodium reduction plus addCon antihypertensive therapy12 mo44-h ABPM151.5/87.1Month 6: ?21.8/?13.3; month 12: ?21.4/?12.5Agarwal (15)2014100Lisinopril group of the HDPAL trialLisinopril (10C40 mg TIW Isoconazole nitrate postdialysis) plus dry weight reduction plus dialysate sodium reduction plus addCon antihypertensive therapy151.9/87.2Month 6: ?16.8/?9.7; month Isoconazole nitrate 12: ?17.9/?9.6 Open in a separate window CFB, change from baseline; HD, hemodialysis; TIW, three times per week; ABPM, ambulatory BP monitoring; MBP, mean BP; DRIP, Dry-Weight Reduction in Hemodialysis Patients; LVH, left ventricular hypertrophy; HDPAL, Hypertension in Hemodialysis Patients Treated with Atenolol or Lisinopril. Nonpharmacologic interventions ((22) showed that, among 360 patients with hypertension on hemodialysis, ARB therapy (valsartan, candersartan, or losartan) reduced by 49% the risk of cardiovascular death, nonfatal myocardial infarction (MI), stroke, coronary revascularization, and hospitalized congestive heart failure (CHF) in comparison with control therapy not including ARBs or ACEIs (hazard ratio [HR], 0.51; 95% CI, 0.33 to 0.79). A meta-analysis of these three studies CREB3L3 showed that ACEI and ARB use was not associated with significant reduction in the risk of future cardiovascular events (pooled RR, 0.66; 95% CI, 0.35 to 1 1.25), indicating the necessity for larger highCquality studies (23). The subsequent Olmesartan Clinical Trial in Okinawa Patients under Okinawa Dialysis Study Trial compared the effect of olmesartan (10C40 mg/d) versus control therapy not including RAAS inhibitors in 469 patients with hypertension on hemodialysis. Over a mean follow-up of 3.5 years, incidence of all-cause death, nonfatal stroke, MI, and coronary revascularization was identical in the ARB and control arms (HR, 1.00; 95% CI, 0.71 to 1 1.40) (24). RAAS blockade is suggested to exert beneficial actions on LVH and large artery stiffness, both of which are strong cardiovascular risk predictors in patients on dialysis (25,26). This notion is supported by small randomized studies showing that, compared with placebo or other therapies, ACEIs and ARBs caused greater reductions in left ventricular mass index (LVMI) and pulse wave velocity (PWV) (Table 2) (27,28). A previous meta-analysis of five randomized studies showed that ACEI or ARB use resulted in a significant reduction in LVMI, with a weighted mean difference of 15.4 g/m2 (95% CI, 7.4 to 23.3) relative to control therapy (23). Improvement in LVMI with ARB therapy was evident in another meta-analysis of six randomized studies (29). However, these benefits were not consistent in all relevant studies. In the recent Saving Residual Renal Function among Hemodialysis Patients Receiving Irbesartan Study, 12-month treatment with irbesartan was not superior to placebo in reducing LVMI and aortic PWV; notably, ARB-induced reductions in LVMI and PWV went in parallel with the changes in predialysis BP (30). Therefore, it remains unclear whether these beneficial actions on cardiac remodeling and arterial stiffness are BP mediated or BP independent (31). Table 2. Randomized studies evaluating the effects of angiotensinCconverting enzyme inhibitors and angiotensin receptor blockers in patients on dialysis (20)2006397HDHypertension (not all patients) and LVHDouble blindPlaceboFosinopril (titrated up to 20 mg/d)24CV death, resuscitated death, nonfatal stroke, MI, hospitalized CHF, and Isoconazole nitrate coronary revascularizationNeutralIncidence of fatal and nonfatal CV events was no different between the fosinopril and placebo groups (RR, 0.93; 95% CI, 0.68 to 1 1.26)Takahashi (21)200680HDWithout overt CV diseaseOpen labelNothingCandesartan (4C8 mg/d)36SCD, fatal or nonfatal MI, unstable angina, hospitalized CHF, serious arrhythmiaBetterCandesartan therapy improved CV eventCfree survival (OR, 0.23; 95% CI, 0.08 to 0.67)Suzuki (22)2008360HDHypertensionOpen labelOther therapy not ACEIs or ARBsLosartan (50C100 mg/d), valsartan (80C160 mg/d), or candesartan (up to 12 mg/d)36Composite of CV death, nonfatal MI, stroke, coronary revascularization, and CHFBetterARB treatment reduced the occurrence of fatal and nonfatal CV events (HR, 0.51; 95% CI, 0.33 to 0.79)Cice (32)2010332HDLVEF 40% on ACEIsDouble blindPlaceboTelmisartan (titrated up to 80 mg/d)36All-cause mortality; CV mortality, hospitalization for CHFBetterAddCon telmisartan therapy reduced all-cause (HR, 0.51; 95% CI, 0.32 to 0.82) and CV mortality (HR, Isoconazole nitrate 0.42; 95% CI, 0.38 to 0.61)Iseki (24)2013469HDHypertensionOpen labelOther therapy not ACEIs.