Safety and Cardiovascular Efficacy of Hydralazine and Isosorbide Dinitrate in Dialysis-Dependent ESRD

Sixteen patients receiving maintenance hemodialysis will be randomized to 26 weeks of therapy
with combination hydralazine/isosorbide dinitrate or placebo. Study medications will be
titrated to goal dose during the first 4 weeks and maintained at goal dose (as tolerated)
between weeks 4-26. A final study visit to assess symptoms after drug discontinuation will
occur 4 weeks after drug discontinuation.

Study duration-Maximum of 32 weeks with 26 weeks of active therapy.

Efficacy Measures -Tissue Doppler echocardiography and myocardial perfusion scanning using
radioactive NH3 PET will be assessed at weeks 0 and 26.

Safety Measures-Adverse events rates including inter- and intra-dialytic hypotension,
,cardiovascular death and gastrointestinal symptoms will be assessed throughout the duration
of the study.

Inclusion Criteria

1. Maintenance hemodialysis therapy for end-stage renal disease

2. Age 18-85 years

3. ≥ 90 days since dialysis initiation

4. Ability to provide informed consent

5. Pre-dialysis seated systolic blood pressure measurements must be ≥ 120 mm Hg in the 2
weeks before enrollment and on the day of randomization.

Exclusion Criteria

1. Serum potassium ≥6.5 mEq/L within 2 months prior to screening

2. Unscheduled dialysis for hyperkalemia within the 3 months prior to screening

3. Hypotension defined as pre-dialysis SBP <100 mm Hg (seated measurement) within 4 weeks
prior to enrollment

4. Recurrent intra-dialytic hypotension, defined as systolic blood pressure <80 mm Hg
during ≥3 dialysis sessions per 30-day rolling period or treatment for either
hypotension or symptoms of hypotension if systolic blood pressure is < 100 mm Hg
during ≥3 dialysis sessions per 30-day rolling period.

5. Mitral valve repair or replacement

6. Severe mitral valve disease by echocardiography, coronary angiography or cardiac
magnetic resonance imaging

7. Prior coronary artery bypass graft

8. Anticipated kidney transplant, change to peritoneal dialysis, or transfer to another
dialysis unit within 6 months

9. Expected survival < 6 months

10. Allergy to study medications (ISD, HY, adenosine/diprimidole)

11. Active use of sildenafil, vardenafil or tadalafil

12. History of severe aortic stenosis or other cause of LV outflow obstruction

13. Pregnancy, anticipated pregnancy, or breastfeeding, confirmed by serum pregnancy test
on the day of PET scan

14. Incarceration

15. Participation in another intervention study

16. Use of monoamine oxidase inhibitors

17. Contraindication to adenosine including

- 2nd or 3rd degree heart block, sick sinus syndrome or symptomatic bradycardia
(without a functioning pacemaker)

- moderate or severe asthma

- chronic obstructive pulmonary disease

18. Active use of any of the study medications unless participant and physician willing to
discontinue prior to enrollment.