Should all hypertensive dialysis patients receive a blocker of the Renin-Angiotensin system?

Cardiovascular mortality and hypertension remain common in the dialysis population, and two recent meta-analyses have suggested that antihypertensive pharmacotherapy reduces cardiovascular events in dialysis patients. Based on their benefits in other populations, blockers of the renin-angiotensin-aldosterone system (RAAS) are an attractive treatment option. The evidence that RAAS blockers improve surrogate end points is mixed. However, a recent meta-analysis found significant improvement in left ventricular mass with RAAS-blocking drugs in hemodialysis patients. Only a few trials have examined RAAS-blocking drugs and cardiovascular events in dialysis patients, and a recent meta-analysis found no significant benefit in hemodialysis patients. The single trial of peritoneal dialysis patients that reported cardiovascular events found no benefit from RAAS blockers. Fortunately, the risk of hyperkalemia appears low. Based on the available evidence, we cannot categorically recommend that all hypertensive dialysis patients be treated with RAAS blockers. We await the results of adequately powered clinical trials.