Patients on chronic dialysis
therapy have a dramatic excess cardiovascular risk compared to any other population, including those with overt
diabetic nephropathy. Despite this, patients on dialysis are almost invariably excluded from trials evaluating the cardioprotective effect of novel treatments. Consistent evidence is available that inhibitors of the renin-angiotensin system, such as
angiotensin-converting enzyme (
ACE) inhibitors or
angiotensin II receptor blockers (ARBs), are more cardioprotective than other
antihypertensive agents in patients with
chronic renal disease or diabetes (with or without renal involvement), but whether this applies also to patients on dialysis is unknown. However, clear evidence is available that
ACE inhibitors and ARBs reduce morbidity and mortality in patients on dialysis with
heart failure (HF) or
atrial fibrillation (AF). Moreover, these drugs may preserve residual renal function in those with preterminal
kidney failure as well as vascular access and peritoneal membrane function in those on extracorporeal or
peritoneal dialysis, respectively. These drugs also show an excellent tolerability profile in this population. Thus,
ACE inhibitors and ARBs are indicated in patients on dialysis with HF or AF. Available evidence suggests that they should be first-choice
therapy in patients on dialysis with
hypertension, though trials are still needed to formally demonstrate their superior cardioprotective effect over other
antihypertensives in this population.