Why angiotensin converting enzyme inhibitors and angiotensin II receptor blockers are not prescribed in the management of hypertension among hemodialysis patients in India.

Despite of well‑established clinical advantages of angiotensin converting enzyme inhibitors (ACEIs) and angiotensin II receptor blockers (ARBs) among hemodialysis patients, they are seldom prescribed. The prevalence of end‑stage renal disease (ESRD) is increasing in India due to diabetes, hypertension, and ageing population. Hypertension is major morbidity affecting 90% of patients on hemodialysis, which is often poorly controlled. [1] According to Kidney Disease Outcomes Quality Initiative clinical practice guidelines, ACEIs and ARBs are the first line choice in chronic kidney disease patients. [2] Numerous clinical studies have been proven the importance of ACEIs and ARBs in reduction of morbidity and mortality; however in India, nephrologists are reluctant and prescribe sparingly ACEIs and ARBs in ESRD patients on hemodialysis. [3,4] This lack of enthusiasm by the nephrologists is attributed to poor infrastructure in terms of monitoring of hyperkalemia, which is mandatory for ACEIs and ARBs regimens. It is a well‑known fact that ACEIs and ARBs were associated with an amplified risk of hyperkalemia in hemodialysis patients, possibly due to blocking the extra renal potassium loss. [5] Increased levels of potassium in extracellular fluid and serum can cause muscle weakness effecting contraction in skeletal muscle, and in cardiac tissue leading to arrhythmia, and cardiac arrest. Due to poor kidney function, the elimination of ACEIs and ARBs is effected and residence time of these drugs gets effected leading to alteration in pharmacokinetic/pharmacodynamic profiles. However, the elimination of various ACEI by hemodialysis is in the order of, lisinopril 50%, benazepril 20‑50%, enalapril 35%, ramipril <30%, fosinopril <10%, captopril (yes) respectively. On the contrary elimination of ARBs is not possible by hemodialysis. [5]