Renin-angiotensin system blockade in heart failure patients on long-term haemodialysis in Taiwan

Effect of renin-angiotensin system inhibitors on cardiovascular events in hemodialysis patients with hyperphosphatemia: A post hoc analysis of the LANDMARK trial

INTRODUCTION

The clinical benefits of renin-angiotensin system inhibitors (RASi) in patients undergoing hemodialysis remain obscure.

METHODS

This is a post hoc cohort analysis of the LANDMARK trial investigate whether RASi use was associated with cardiovascular events (CVEs) and all-cause mortality. A total of 2135 patients at risk for vascular calcification were analyzed using a Cox proportional hazards model with propensity-score matching.

RESULTS

The risk of CVEs was similar between participants with RASi use at baseline and those without RASi use at baseline and between participants with RASi use during the study period and those without RASi use during the study period. No clinical benefits of RASi use on all-cause mortality were observed. Serum phosphate levels were significantly associated with the effect of RASi on CVEs.

CONCLUSIONS

RASi use was not significantly associated with a lower risk of CVEs or all-cause mortality in hemodialysis patients at risk of vascular calcification.

Managing Heart Failure in Patients on Dialysis: State-of-the-Art Review

Heart failure (HF) and end-stage kidney disease (ESKD) frequently coexist; 1 comorbidity worsens the prognosis of the other. HF is responsible for almost half the deaths of patients on dialysis. Despite patients' with ESKD composing an extremely high-risk population, they have been largely excluded from landmark clinical trials of HF, and there is, thus, a paucity of data regarding the management of HF in patients on dialysis, and most of the available evidence is observational. Likewise, in clinical practice, guideline-directed medical therapy for HF is often down-titrated or discontinued in patients with ESKD who are undergoing dialysis; this is due to concerns about safety and tolerability. In this state-of-the-art review, we discuss the available evidence for each of the foundational HF therapies in ESKD, review current challenges and barriers to managing patients with HF on dialysis, and outline future directions to optimize the management of HF in these high-risk patients.

Prognostic and Therapeutic Implications of Renal Insufficiency in Heart Failure

The heart and kidneys are closely related vital organs that significantly affect each other. Cardiorenal syndrome is the term depicting the various spectra of cardiorenal interaction mediated by the hemodynamic, neurohormonal, and biochemical cross-talk between these two organs. In patients with heart failure (HF), both the baseline and worsening renal function are closely related to prognosis. However, for both investigational and clinical purposes, the unified definition and classification of renal injury are still necessary. Renal insufficiency is caused by multiple factors, and categorizing them into monogenous subgroups of phenotype is difficult. Various clinical scenarios related to the chronicity of HF, progression of renal dysfunction, and issues related to pharmacologic therapies associated with the prognosis of patients with HF have been reviewed in this study.

Heart failure management in dialysis patients: Many treatment options with no clear evidence

Heart failure with reduced ejection fraction (HFrEF) impacts approximately 20% of dialysis patients and is associated with high mortality rates. Key issues discussed in this review of HFrEF management in dialysis include dialysis modality choice, vascular access, dialysate composition, pharmacological therapies, and strategies to reduce sudden cardiac death, including the use of cardiac devices. Peritoneal dialysis and more frequent or longer duration of hemodialysis may be better tolerated due to slower ultrafiltration rates, leading to less intradialytic hypotension and better volume control; dialysate cooling and higher dialysate calcium may also have benefits. While high-quality evidence exists for many drug classes in the non-dialysis population, dialysis patients were excluded from major trials, and only limited data exist for many medications in kidney failure patients. Despite limited evidence, beta blocker and angiotensin-converting enzyme inhibitor or angiotensin receptor blocker use is common in dialysis. Similarly, devices such as implantable cardiac defibrillators (ICDs) and cardiac resynchronization therapy that have proven benefits in non-dialysis HFrEF patients have not consistently been beneficial in the limited dialysis studies. The use of leadless pacemakers and subcutaneous ICDs can mitigate future hemodialysis access limitations. Additional research is critical to address knowledge gaps in treating maintenance dialysis patients with HFrEF.

Interactive Effectiveness of Angiotensin-Converting Enzyme Inhibitors and Angiotensin Receptor Blockers or Their Combination on Survival of Hemodialysis Patients

BACKGROUND

Does the use of angiotensin-converting enzyme inhibitors and angiotensin receptor blockers individually or as a combination confer a survival benefit in hemodialysis patients? The answer to this question is yet unclear.

METHODS

We performed a case-cohort study using data from the Mineral and Bone Disorder Outcomes Study for Japanese CKD stage 5D patients (MBD-5D), a 3-year multicenter prospective case-cohort study, including 8,229 hemodialysis patients registered from 86 facilities in Japan. All patients had secondary hyperparathyroidism, a condition defined as a parathyroid hormone level ≥180 pg/mL and/or receiving vitamin D receptor activators. We compared all-cause mortality rates between those receiving ACEI, ARB, and their combination and non-users with interaction testing. We used marginal structural Poisson regression (causal model) to estimate the causal effect and interaction adjusted for possible time-dependent confounding. Cardiovascular mortality was also evaluated.

RESULTS

Among 3,762 randomly sampled subcohort patients, those taking ACEI, ARB, and their combination at baseline accounted for 4.0, 31.6, and 3.8%, respectively. Over 3 years, 1,226 all-cause and 462 cardiovascular deaths occurred. Compared to non-users, ARB-alone users had a lower all-cause mortality rate (adjusted incident rate ratio [aIRR] 0.62, 95% CI 0.50-0.76), whereas ACEI-alone users showed a statistically similar rate (aIRR 1.01, 95% CI 0.57-1.77). On the contrary, combination users had a greater mortality rate (aIRR 2.56, 95% CI 1.22-5.37), showing significant interaction (p = 0.03). Analysis for cardiovascular mortality showed similar results.

CONCLUSION

Among hemodialysis patients with secondary hyperparathyroidism, unlike ACEI use, ARB use was associated with greater survival than non-use. Conversely, combination use was associated with greater mortality. Controlled trials are warranted to verify the causality factors of these associations.

The evaluation of β-adrenoceptor blocking agents in patients with COPD and congestive heart failure: a nationwide study

OBJECTIVE

β-Blockers are safe and improve survival in patients with both congestive heart failure (CHF) and COPD. However, the superiority of different types of β-blockers is still unclear among patients with CHF and COPD. The association between β-blockers and CHF exacerbation as well as COPD exacerbation remains unclear. The objective of this study was to compare the outcome of different β-blockers in patients with concurrent CHF and COPD.

PATIENTS AND METHODS

We used the National Health Insurance Research Database in Taiwan to conduct a retrospective cohort study. The inclusion criteria for CHF were patients who were >20 years old and were diagnosed with CHF between January 1, 2005 and December 31, 2012. COPD patients included those who had outpatient visit claims ≥2 times within 365 days or 1 claim for hospitalization with a COPD diagnosis. A time-dependent Cox proportional hazards regression model was applied to evaluate the effectiveness of β-blockers in the study population.

RESULTS

We identified 1,872 patients with concurrent CHF and COPD. Only high-dose bisoprolol significantly reduced the risk of death and slightly decreased the hospitalization rate due to CHF exacerbation (death: adjusted hazard ratio [aHR] =0.51, 95% confidence interval [CI] =0.29-0.89; hospitalization rate due to CHF exacerbation: aHR =0.48, 95% CI =0.23-1.00). No association was observed between β-blocker use and COPD exacerbation.

CONCLUSION

In patients with concurrent CHF and COPD, β-blockers reduced mortality, CHF exacerbation, and the need for hospitalization. Bisoprolol was found to reduce mortality and CHF exacerbation compared to carvedilol and metoprolol.

Economic costs of automated and continuous ambulatory peritoneal dialysis in Taiwan: a combined survey and retrospective cohort analysis

OBJECTIVES

Taiwan succeeded in raising the proportion of peritoneal dialysis (PD) usage after the National Health Insurance (NHI) payment scheme introduced financial incentives in 2005. This study aims to compare the economic costs between automated PD (APD) and continuous ambulatory PD (CAPD) modalities from a societal perspective.

DESIGN AND SETTING

A retrospective cohort of patients receiving PD from the NHI Research Database was identified during 2004-2011. The 1:1 propensity score matched 1749 APD patients and 1749 CAPD patients who were analysed on their NHI-financed medical costs and utilisation. A multicentre study by face-to-face interviews on 117 APD and 129 CAPD patients from five hospitals located in four regions of Taiwan was further carried out to collect data on their out-of-pocket payments, productivity losses and quality of life with EuroQol-5D-5L.

OUTCOME MEASURES

The NHI-financed medical costs, out-of-pocket payments and productivity losses of APD and CAPD patients.

RESULTS

The total NHI-financed medical costs per patient-year after 5 years of follow-up were significantly higher with APD than CAPD (US$23 005 vs US$19 237; p<0.01). In terms of dialysis-related costs, APD had higher costs resulting from the use of APD machines (US$795) and APD sets (US$2913). Significantly lower productivity losses were found with APD (US$2619) than CAPD (US$6443), but the out-of-pocket payments were not significantly different. The differences in NHI-financed medical costs and productivity losses between APD and CAPD remained robust in the bootstrap analysis. The total economic costs of APD (US$30 401) were similar to those of CAPD (US$29 939), even after bootstrap analysis (APD, US$28 399; CAPD, US$27 960). No discernable differences were found in the results of mortality and quality of life between the APD and CAPD patients.

CONCLUSIONS

APD had higher annual dialysis-related costs and lower annual productivity losses than CAPD, which made the economic costs of APD very close to those of CAPD in Taiwan.

Effect of pulmonary tuberculosis on clinical outcomes of long-term dialysis patients: Pre- and post-DOTS implementation in Taiwan

BACKGROUND AND OBJECTIVE

The link between tuberculosis (TB) and dialysis is known; however, the impact of TB on the clinical outcomes remains to be elucidated. This study aims to determine the clinical consequences of pulmonary TB among patients under long-term dialysis.

METHODS

A retrospective propensity-scores matched (1:4) cohort study was conducted by retrieving patient data for pulmonary TB after long-term dialysis commencement from the Taiwan National Health Insurance Research Database between 1999 and 2013. Patients with TB (n = 1993) or without TB (n = 7972) were compared for 3-year morbidity and mortality. The effect of Directly Observed Treatment, Short-Course (DOTS) implementation was also evaluated. Cox proportional hazards models were used to determine adjusted hazard ratios (HRs).

RESULTS

TB patients had a significantly higher risk of mortality than non-TB patients even after multivariate adjustment (HR: 1.48; 95% CI: 1.36-1.60; P < 0.001). DOTS implementation reduced the risk of some morbidities such as pneumonia, hospitalization and intensive care unit stay >7 days, but not inotropic agent usage, ventilator therapy >21 days and mortality in TB patients. In pulmonary TB patients with treatment duration ≥180 days, DOTS implementation also lowered the risk of TB relapse (HR: 0.33; 95% CI: 0.19-0.55; P < 0.001), irrespective of treatment duration (180-224 or ≥225 days).

CONCLUSION

Pulmonary TB increases the risk of morbidity and mortality in dialysis patients; DOTS implementation reduces some morbidities and TB relapse. Continuing DOTS implementation should be encouraged to improve clinical outcomes in dialysis patients.

Do Automated Peritoneal Dialysis and Continuous Ambulatory Peritoneal Dialysis Have the Same Clinical Outcomes? A Ten-year Cohort Study in Taiwan

This paper reports a comprehensive comparison for mortality and technique failure rates between automated peritoneal dialysis (APD) and continuous ambulatory peritoneal dialysis (CAPD) in Taiwan. A propensity-score matched cohort study was conducted by retrieving APD and CAPD patients identified from the Taiwan National Health Insurance Research Database between 2001 and 2010. The main outcomes were the 5-year mortality and technique failure rates. Further analyses were then carried out based upon the first (2001–2004), second (2005–2007), and third (2008–2010) sub-periods. Similar baseline characteristics were identified for APD (n = 2,287) and CAPD (n = 2,287) patients. The proportion on APD therapy increased rapidly in the second sub-period. As compared to CAPD patients of this sub-period, APD patients had a significantly higher risk of mortality (HR, 1.37; 95% CI 1.09–1.72; p < 0.01) and technique failure (HR, 1.43; 95% CI, 1.10–1.86; p < 0.01), particularly in the first year after peritoneal dialysis commencement. However, APD patients had similar mortality and technique failure rates to those of CAPD patients throughout the full sample period and the first and third sub-periods. These findings do not suggest the presence of a clear advantage of CAPD over APD. Differences observed between these two modalities might be attributed to specials circumstances of sub-periods.

Prognostic Benefits of Carvedilol, Bisoprolol, and Metoprolol Controlled Release/Extended Release in Hemodialysis Patients with Heart Failure: A 10-Year Cohort

BACKGROUND

Heart failure is a highly prevalent cardiovascular complication among patients receiving long-term hemodialysis, but the benefits of carvedilol, bisoprolol, and metoprolol controlled release/extended release on the outcomes of these patients remain unclear. In this study, we address the use of these 3 β-blockers and their associations with mortality.

METHODS AND RESULTS

Long-term hemodialysis patients, aged ≥35 years, with new-onset heart failure and receiving various medications were identified through the use of 1999-2010 data from the Taiwan National Health Insurance Research Database. From the total of 4435 heart failure patients, we selected 1700 new users of the 3 β-blockers (study group) and 1700 nonusers (control group), by using matched cohorts according to their propensity scores, and then compared the 5-year all-cause mortality rates by using Cox proportional hazard regressions and time-dependent covariate adjustment. During 3944 person-years of follow-up, 666 (39.2%) deaths occurred within the study group, compared with 918 (54%) deaths during 2893 person-years of follow-up in the control group. The 5-year mortality rate for the study (control) group was 54.5% (70.3%); P<0.001. Adjusted hazard regression analyses revealed that the therapeutic effects of β-blockers remained significant for all-cause mortality (hazard ratio 0.80, 95% CI 0.72 to 0.90). Subgroup analyses revealed that patients in the study group receiving β-blockers plus renin-angiotensin system antagonists exhibited the lowest mortality rate, while the highest mortality rate was found among patients in the control group receiving neither β-blockers nor renin-angiotensin system antagonists.

CONCLUSIONS

This study demonstrates that the 3 β-blockers were associated with improved survival in long-term hemodialysis patients with heart failure.

Some Aspects of the Renin-Angiotensin-System in Hemodialysis Patients

Understanding of the renin-angiotensin system (RAS) has changed remarkably over the past decade. Renin, angiotensin converting enzyme (ACE), angiotensin II (Ang II), and Ang II receptors are the main components of the RAS. Recent studies identified the ACE2/Ang 1–7/ Mas receptor axis, which counter-regulates the classical RAS. Many studies have examined the effects of the RAS on the progression of cardiovascular disease and chronic kidney disease (CKD). In addition, many studies have documented increased levels of ACE in hemodialysis (HD) patients, raising concerns about the negative effects of RAS activation on the progression of renal disease. Elevated ACE increases the level of Ang II, leading to vasoconstriction and cell proliferation. Ang II stimulation of the sympathetic system leads to renal and cardiovascular complications that are secondary to uncontrolled hypertension. This review provides an overview of the RAS, evaluates new research on the role of ACE2 in dialysis, and reviews the evidence for potentially better treatments for patients undergoing HD. Further understanding of the role of ACE and ACE2 in HD patients may aid the development of targeted therapies that slow the progression of CKD and cardiovascular disease.

Impact of use of angiotensin II receptor blocker on all-cause mortality in hemodialysis patients: prospective cohort study using a propensity-score analysis

BACKGROUND

It is controversial whether treatment with an angiotensin II receptor blocker (ARB) or a calcium channel blocker (CCB) improves prognosis of hemodialysis (HD) patients.

METHODS

This study was designed as a multicenter prospective cohort study. HD patients (n = 1071) were enrolled from 22 institutes in January 2009 and followed up for 3 years. Patients with missing data, kidney transplantation or retraction of consent during the follow-up period (n = 204) were excluded, and 867 patients contributed to analysis of mortality. Propensity score (PS) for use of ARB and that for CCB was calculated using a multiple logistic regression model.

RESULTS

ARB and CCB were prescribed in 45.6 and 54.7 % of patients at enrollment. During the 3-year follow-up period, all-cause mortality and cardiovascular mortality rates were 18.8 and 5.1 %, respectively. Kaplan-Meier curves showed that all-cause and cardiovascular mortality rates were lower in the ARB group than in the non-ARB group, though the mortality rates were similar in the CCB group and non-CCB group. In PS-stratified Cox regression analysis, ARB treatment was associated with 34 and 45 % reduction of all-cause death and cardiovascular death, respectively. In PS matching analysis, ARB treatment was associated with a significant reduction (46 % reduction) in the risk of all-cause death. A significant impact of CCB treatment on all-cause or cardiovascular mortality was not detected in PS analysis.

CONCLUSIONS

The use of an ARB, but not a CCB, is associated with reduced all-cause and cardiovascular mortalities in patients on HD.

Angiotensin Receptor Blockers Decrease the Risk of Major Adverse Cardiovascular Events in Patients with End-Stage Renal Disease on Maintenance Dialysis: A Nationwide Matched-Cohort Study

Background

Major adverse cardiovascular events (MACE) cause the leading cause of morbidity and mortality in patients with end-stage renal disease (ESRD) on maintenance Hemodialysis (HD) or peritoneal dialysis (PD). Many randomized-controlled trials (RCTs) have proved that angiotensin receptor blockers (ARBs) can reduce the risk of MACE in the people with normal or impaired kidney function without dialysis. This study seeks to clarify whether ARBs therapy could also attenuate this risk in patients with ESRD on maintenance dialysis.

Materials and Methods

The National Health Research Institute provided a database of one million random subjects for the study. A random sample was taken of 1800 patients ≥18 years y/o with ESRD on dialysis without a history of MACE and use of ARBs within 6-months prior to enrollment. Cox proportional hazard regression analysis was used to identify the risk factors and compute the hazard ratios accompanying 95% confidence intervals.

Results

In these 1800 patients, 1061 had never used ARBs, while 224 had used them for 1–90 days, and 515 had used them for more than 90 days. We found that ARBs significantly decrease the incidences of acute myocardial infarctions (AMI), coronary artery diseases (CAD) requiring coronary stent or percutaneous transluminal coronary angioplasty (PTCA), peripheral artery disease (PAD) requiring percutaneous transluminal angioplasty (PTA), and acute stroke. Cumulative prescription days of ARBs beyond 365–760 days or more were found to be negatively correlated with incidence of MACEs. For patients with dual comorbidity (i.e., mellitus and hyperlipidemia), 91–365 cumulative prescription days might also attenuate the risk.

Conclusions

For patients on maintenance dialysis, the use of ARBs could significantly attenuate the risk of major cardiovascular events: AMI, acute stroke, and PAD requiring PTA.

Comparative Effectiveness of Angiotensin-Converting Enzyme Inhibitors and Angiotensin II Receptor Blockers in Terms of Major Cardiovascular Disease Outcomes in Elderly Patients: A Nationwide Population-Based Cohort Study

Renin and aldosterone activity levels are low in elderly patients, raising concerns about the benefits and risks of angiotensin-converting-enzyme inhibitors (ACEIs) and angiotensin II receptor blockers (ARB) use. However, data from direct comparisons of the effects of ACEIs on ARBs in the elderly population remain inconclusive.In this nationwide study, all patients aged ≥ 70 years were retrieved from the Taiwan National Health Insurance database for the period 2000 to 2009 and were followed up until the end of 2010. The ARB cohort (12,347 patients who continuously used ARBs for ≥ 90 days) was matched to ACEI cohort using high-dimensional propensity score (hdPS). Intention-to-treat (ITT) and as-treated (AT) analyses were conducted.In the ITT analysis, after considering death as a competing risk, the ACEI cohort had similar risks of myocardial infarction (hazard ratio [HR] 0.92, 95% confidence interval [CI] 0.79-1.06), ischemic stroke (HR 0.98, 95% CI 0.90-1.07), and heart failure (HR 0.93, 95% CI 0.83-1.04) compared with the ARB cohort. No difference in adverse effects, such as acute kidney injury (HR 0.99, 95% CI 0.89-1.09) and hyperkalemia (HR 1.02, 95% CI 0.87-1.20), was observed between cohorts. AT analysis produced similar results to those of ITT analysis. We were unable to demonstrate a survival difference between cohorts (HR 1.03, 95% CI 0.88-1.21) after considering drug discontinuation as a competing risk in AT analysis.Our study supports the notion that ACEI and ARB users have similar risks of major adverse cardiovascular events (MACE), even in elderly populations.