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Toye C, Sood MM, Mallick R, Akbari A, Bieber B, Karaboyas A, Guedes M, Hundemer GL. Comparison of β-blocker agents and mortality in maintenance hemodialysis patients: an international cohort study. Clin Kidney J 2024; 17:sfae087. [PMID: 38887596 PMCID: PMC11181867 DOI: 10.1093/ckj/sfae087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Indexed: 06/20/2024] Open
Abstract
Background Despite a lack of clinical trial data, β-blockers are widely prescribed to dialysis patients. Whether specific β-blocker agents are associated with improved long-term outcomes compared with alternative β-blocker agents in the dialysis population remains uncertain. Methods We analyzed data from an international cohort study of 10 125 patients on maintenance hemodialysis across 18 countries that were newly prescribed a β-blocker medication within the Dialysis Outcomes and Practice Patterns Study (DOPPS). The following β-blocker agents were compared: metoprolol, atenolol, bisoprolol and carvedilol. Multivariable Cox proportional hazards models were used to estimate the association between the newly prescribed β-blocker agent and all-cause mortality. Stratified analyses were performed on patients with and without a prior history of cardiovascular disease. Results The mean (standard deviation) age in the cohort was 63 (15) years and 57% of participants were male. The most commonly prescribed β-blocker agent was metoprolol (49%), followed by carvedilol (29%), atenolol (11%) and bisoprolol (11%). Compared with metoprolol, atenolol {adjusted hazard ratio (HR) 0.77 [95% confidence interval (CI) 0.65-0.90]} was associated with a lower mortality risk. There was no difference in mortality risk with bisoprolol [adjusted HR 0.99 (95% CI 0.82-1.20)] or carvedilol [adjusted HR 0.95 (95% CI 0.82-1.09)] compared with metoprolol. These results were consistent upon stratification of patients by presence or absence of a prior history of cardiovascular disease. Conclusions Among patients on maintenance hemodialysis who were newly prescribed β-blocker medications, atenolol was associated with the lowest mortality risk compared with alternative agents.
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Affiliation(s)
- Corey Toye
- Department of Medicine, Division of Nephrology, University of Ottawa, Ottawa, ON, Canada
| | - Manish M Sood
- Department of Medicine, Division of Nephrology, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Ranjeeta Mallick
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Ayub Akbari
- Department of Medicine, Division of Nephrology, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Brian Bieber
- Arbor Research Collaborative for Health, Ann Arbor, MI, USA
| | | | - Murilo Guedes
- Arbor Research Collaborative for Health, Ann Arbor, MI, USA
| | - Gregory L Hundemer
- Department of Medicine, Division of Nephrology, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
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Kang SH, Kim BY, Son EJ, Kim GO, Do JY. Influence of Different Types of β-Blockers on Mortality in Patients on Hemodialysis. Biomedicines 2023; 11:2838. [PMID: 37893212 PMCID: PMC10603865 DOI: 10.3390/biomedicines11102838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 10/08/2023] [Accepted: 10/17/2023] [Indexed: 10/29/2023] Open
Abstract
Previous results regarding the association between types of β-blockers and outcomes in patients on hemodialysis (HD) were inconsistent. Our study aimed to evaluate patient survival according to the type of β-blockers administered using a large sample of patients with maintenance HD. Our study included patients on maintenance HD patients from a national HD quality assessment program (n = 54,132). We divided included patients into four groups based on their use and type; Group 1 included patients without a prescription of β-blockers, Group 2 included patients with a prescription of dialyzable and cardioselective β-blockers, Group 3 included patients with a prescription of non-dialyzable and non-cardioselective β-blockers, and Group 4 included patients with prescription of non-dialyzable and cardioselective β-blockers. The number of patients in Groups 1, 2, 3, and 4 were 34,514, 2789, 15,808, and 1021, respectively. The 5-year survival rates in Groups 1, 2, 3, and 4 were 69.3%, 66.0%, 68.8%, and 69.2%, respectively. Univariate Cox regression analyses showed the hazard ratios to be 1.10 (95% CI, 1.04-1.17) in Group 2 and 1.05 (95% CI, 1.02-1.09) in Group 3 compared to Group 1. However, multivariate Cox regression analyses did not show statistical significance among the four groups. Our study showed that there was no significant difference in patient survival based on the use or types of β-blockers.
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Affiliation(s)
- Seok-Hui Kang
- Division of Nephrology, Department of Internal Medicine, College of Medicine, Yeungnam University, Daegu 42415, Republic of Korea;
| | - Bo-Yeon Kim
- Healthcare Review and Assessment Committee, Health Insurance Review and Assessment Service, Wonju 26465, Republic of Korea
| | - Eun-Jung Son
- Quality Assessment Department, Health Insurance Review and Assessment Service, Wonju 26465, Republic of Korea
| | - Gui-Ok Kim
- Quality Assessment Department, Health Insurance Review and Assessment Service, Wonju 26465, Republic of Korea
| | - Jun-Young Do
- Division of Nephrology, Department of Internal Medicine, College of Medicine, Yeungnam University, Daegu 42415, Republic of Korea;
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Haddiya I, Valoti S. Current Knowledge of Beta-Blockers in Chronic Hemodialysis Patients. Int J Nephrol Renovasc Dis 2023; 16:223-230. [PMID: 37849744 PMCID: PMC10578177 DOI: 10.2147/ijnrd.s414774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 09/29/2023] [Indexed: 10/19/2023] Open
Abstract
Beta-blockers include a large spectrum of drugs with various specific characteristics, and a well-known cardioprotective efficacy. They are recommended in heart failure, hypertension and arrhythmia. Their use in chronic hemodialysis patients is still controversial, mainly because of the lack of specific randomized clinical trials. Large observational studies and two important clinical trials have reported almost unanimously their efficacy in chronic hemodialysis patients, which seems to be related to their levels of dialyzability and cardioselectivity. A recent meta-analysis suggested that high dialyzable beta-blockers are correlated to a reduced risk of all-cause mortality and cardiovascular complications compared with low dialyzable beta-blockers. Despite their benefits, beta-blockers may have adverse effects, such as intradialytic hypotension with low dialyzability beta-blockers or the risk of sub-therapeutic plasma concentration of high dialyzable ones during dialysis sessions. Both cases are linked to adverse cardiovascular events. A solution for both high and low dialyzable drugs could be their administration after dialysis sessions. Futhermore, the bulk of existing literature seems to favor cardioselective beta-blockers with moderate-to-high dialyzability as the ideal agents in dialysis patients, but further, larger studies are needed. This review aims to analyze beta-blockers' characteristics, indications and evidence-based role in chronic hemodialysis patients.
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Affiliation(s)
- Intissar Haddiya
- Department of Nephrology, Faculty of Medicine and Pharmacy, University Mohamed Premier, Oujda, Morocco
- Laboratory of Epidemiology, Clinical Research and Public Health, Faculty of Medicine and Pharmacy, University Mohamed Premier, Oujda, Morocco
| | - Siria Valoti
- Department of Medicine, Faculty of Medicine, Università degli Studi di Milano Statale, Milano, Italia
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4
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Kang SH, Kim BY, Son EJ, Kim GO, Do JY. Association of Renin-Angiotensin System Blockers with Survival in Patients on Maintenance Hemodialysis. J Clin Med 2023; 12:jcm12093301. [PMID: 37176742 PMCID: PMC10179028 DOI: 10.3390/jcm12093301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 04/19/2023] [Accepted: 05/03/2023] [Indexed: 05/15/2023] Open
Abstract
Additional studies are needed to confirm whether the use of renin-angiotensin system blockers (RASBs) induces survival benefits in patients on hemodialysis (HD). This study aimed to evaluate patient survival with the use of RASBs in a large sample of maintenance HD patients. This study used data from the national HD quality assessment program and claim data from South Korea (n = 54,903). A patient using RASBs was defined as someone who had received more than one prescription during the 6 months of each HD quality assessment period. The patients were divided into three groups as follows: Group 1, no prescription for anti-hypertensive drugs; Group 2, prescription for anti-hypertensive drugs other than RASBs; and Group 3, prescription for RASBs. The five-year survival rates in Groups 1, 2, and 3 were 72.1%, 64.5%, and 66.6%, respectively (p < 0.001 for Group 1 vs. Group 2 or 3; p = 0.001 for Group 2 vs. Group 3). Group 1 had the highest patient survival rates among the three groups, and Group 3 had higher patient survival rates compared to Group 2. Group 3 had higher patient survival rates than Group 2; however, the difference in patient survival rates between Group 2 and Group 3 was relatively small. Multivariate Cox regression analyses showed similar trends as those of univariate analyses. The highest survival rates from our study were those of patients who had not used anti-hypertensive drugs. Between patients treated with RASBs and those with other anti-hypertensive drugs, patient survival rates were higher in patients treated with RASBs.
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Affiliation(s)
- Seok Hui Kang
- Division of Nephrology, Department of Internal Medicine, College of Medicine, Yeungnam University, Daegu 42415, Republic of Korea
| | - Bo Yeon Kim
- Healthcare Review and Assessment Committee, Health Insurance Review and Assessment Service, Wonju 26465, Republic of Korea
| | - Eun Jung Son
- Quality Assessment Department, Health Insurance Review and Assessment Service, Wonju 26465, Republic of Korea
| | - Gui Ok Kim
- Quality Assessment Department, Health Insurance Review and Assessment Service, Wonju 26465, Republic of Korea
| | - Jun Young Do
- Division of Nephrology, Department of Internal Medicine, College of Medicine, Yeungnam University, Daegu 42415, Republic of Korea
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Yeh TH, Tu KC, Hung KC, Chuang MH, Chen JY. Impact of type of dialyzable beta-blockers on subsequent risk of mortality in patients receiving dialysis: A systematic review and meta-analysis. PLoS One 2022; 17:e0279680. [PMID: 36584227 PMCID: PMC9803304 DOI: 10.1371/journal.pone.0279680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 12/12/2022] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Beta-blockers has been reported to improve all-cause mortality and cardiovascular mortality in patients receiving dialysis, but type of beta-blockers (i.e., high vs. low dialyzable) on patient outcomes remains unknown. This study aimed at assessing the outcomes of patients receiving dialyzable beta-blockers (DBBs) compared to those receiving non-dialyzable beta-blockers (NDBBs). METHODS We searched the databases including PubMed, Embase, Cochrane, and ClinicalTrials.gov until 28 February 2022 to identify articles investigating the impact of DBBs/NDBBs among patients with renal failure receiving hemodialysis/peritoneal dialysis (HD/PD). The primary outcome was risks of all-cause mortality, while the secondary outcomes included risk of overall major adverse cardiac event (MACE), acute myocardial infarction (AMI) and heart failure (HF). We rated the certainty of evidence (COE) by Cochrane methods and the GRADE approach. RESULTS Analysis of four observational studies including 75,193 individuals undergoing dialysis in hospital and community settings after a follow-up from 180 days to six years showed an overall all-cause mortality rate of 11.56% (DBBs and NDBBs: 12.32% and 10.7%, respectively) without significant differences in risks of mortality between the two groups [random effect, aHR 0.91 (95% CI, 0.81-1.02), p = 0.11], overall MACE [OR 1.03 (95% CI, 0.78-1.38), p = 0.82], and AMI [OR 1.02 (95% CI, 0.94-1.1), p = 0.66]. Nevertheless, the pooled odds ratio of HF among patients receiving DBBs was lower than those receiving NDBB [random effect, OR 0.87 (95% CI, 0.82-0.93), p<0.001]. The COE was considered low for overall MACE, AMI and HF, while it was deemed moderate for all-cause mortality. CONCLUSIONS The use of dialyzable and non-dialyzable beta-blockers had no impact on the risk of all-cause mortality, overall MACE, and AMI among dialysis patients. However, DBBs were associated with significant reduction in risk of HF compared with NDBBs. The limited number of available studies warranted further large-scale clinical investigations to support our findings.
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Affiliation(s)
- Tzu-Hsuan Yeh
- Department of I nternal Medicine, Chi Mei Medical Center, Tainan, Taiwan
| | - Kuan-Chieh Tu
- Department of I nternal Medicine, Chi Mei Medical Center, Tainan, Taiwan
| | - Kuo-Chuan Hung
- Department of Anesthesiology, Chi Mei Medical center, Tainan, Taiwan
| | - Min-Hsiang Chuang
- Department of I nternal Medicine, Chi Mei Medical Center, Tainan, Taiwan
| | - Jui-Yi Chen
- Division of Nephrology, Department of Internal Medicine, Chi Mei Medical Center, Tainan, Taiwan
- Department of Health and Nutrition, Chia Nan University of Pharmacy and Science, Tainan, Taiwan
- * E-mail:
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Tao S, Huang J, Xiao J, Ke G, Fu P. Cardio-selective versus non-selective β-blockers for cardiovascular events and mortality in long-term dialysis patients: A systematic review and meta-analysis. PLoS One 2022; 17:e0279171. [PMID: 36534654 PMCID: PMC9762568 DOI: 10.1371/journal.pone.0279171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Accepted: 11/16/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Trials in patients receiving dialysis have demonstrated that β-blockers reduce all-cause mortality and cardiovascular events. However, differences still exist within-class comparative effectiveness studies of the therapeutic benefits of β-blockers in dialysis patients. OBJECTIVE The purpose of this systematic review is to examine whether cardiovascular events and all-cause mortality differed between dialysis patients receiving cardio-selective and non-selective agents. METHODS A comprehensive search of relevant articles from the PubMed, EMBASE, Cochrane Central Register and ClinicalTrials.gov was performed up to September 4, 2022, we included adults receiving β-blockers to evaluate the effects of cardio-selective versus non-selective agents on mortality and cardiovascular events in the dialysis population. Hazard ratios (HRs) and 95% confidence intervals (CIs) were examined for the negative outcomes of cardiovascular events and death for any reason. The risk of bias in randomized controlled trials (RCTs) was assessed using Cochrane's risk of bias tool and the risk of bias in observational studies was assessed using a table designed according to the ROBINS-I tool, the evidence grade was assessed using the GRADE guideline. For all-cause mortality and cardiovascular events, the RevMan software (version 5.3) was used to calculate pooled HRs with 95% CI. The heterogeneity (I2) in statistics was used to examine the degree of heterogeneity among studies. RESULTS Four observational studies, including 58, 652 long-term dialysis patients, were included in the meta-analysis. Compared to dialysis patients who took non-selective β-blockers, who took cardio-selective β-blockers was probably associated with fewer cardiovascular events (hazard ratio [HR] = 0.85, 95% confidence interval [CI] = 0.81, 0.89, heterogeneity [I2] = 0%, three trials, 52,077 participants, moderate-quality evidence) and may have lower all-cause mortality (HR = 0.83, 95% CI = 0.69, 0.99, I2 = 91%, four trials, 54,115 participants, low-quality evidence). CONCLUSIONS This systematic review showed that cardio-selective β-blockers are probably associated with fewer cardiovascular events and may have lower all-cause mortality in long-term dialysis patients than non-selective β-blockers. The present study results need to be replicated using randomized controlled trials with longer observation durations.
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Affiliation(s)
- Shaohua Tao
- Kidney Research Institute, Division of Nephrology, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Junlin Huang
- Department of Cardiology, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
| | - Jie Xiao
- Department of Nephrology, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Guibao Ke
- Department of Nephrology, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Ping Fu
- Kidney Research Institute, Division of Nephrology, West China Hospital of Sichuan University, Chengdu, Sichuan, China
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Tella A, Vang W, Ikeri E, Taylor O, Zhang A, Mazanec M, Raju S, Ishani A. β-Blocker Use and Cardiovascular Outcomes in Hemodialysis: A Systematic Review. Kidney Med 2022; 4:100460. [PMID: 35539430 PMCID: PMC9079357 DOI: 10.1016/j.xkme.2022.100460] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Rationale & Objective There is conflicting evidence regarding the type of β-blockers to use in dialysis patients. This systematic review seeks to determine whether highly dialyzable β-blockers are associated with higher rates of cardiovascular events and mortality in hemodialysis patients than poorly dialyzable β-blockers. Study Design A systematic review of the existing literature was conducted. A meta-analysis was performed using data from the selected studies. Setting & Study Populations Participants were from the United States, Canada, and Taiwan. The mean ages of participants ranged from 55.9-75.7 years. Selection Criteria for Studies We searched the Ovid MEDLINE database from 1990 to September 2020. Studies without adult hemodialysis participants and without comparisons of at least 2 β-blockers of different dialyzability were excluded. Data Extraction Baseline and adjusted outcome data were extracted from each study. Analytical Approach Random-effects models were used to calculate pooled risk ratios using fully adjusted models from individual studies. Results Four cohort studies were included. Pooling fully adjusted models, highly dialyzable β-blockers did not influence mortality (HR, 0.94; 95% CI, 0.81-1.08; I2 = 0.84) compared with poorly dialyzable β-blockers but were associated with a reduction in cardiovascular events (HR, 0.88; 95% CI, 0.83-0.93). There was significant heterogeneity between studies (I2 = 0.35). Only 1 study reported on adverse events. Intradialytic hypotension was more common in those on carvedilol (a poorly dialyzable β-blocker) compared with those on metoprolol (a highly dialyzable β-blocker; adjusted incidence rate ratio, 1.10; 95% CI, 1.09-1.11). Limitations No randomized controlled trials were identified. Each study used different analytic methods and different definitions for outcomes. Classifications of β-blockers varied. Only 1 study reported on adverse events. Conclusions Pooled data suggest highly dialyzable β-blockers are associated with similar mortality events and fewer cardiovascular events compared with poorly dialyzable β-blockers.
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8
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Georgianos PI, Eleftheriadis T, Liakopoulos V. Should We Use Dialyzable β-Blockers in Hemodialysis? Kidney Med 2022; 4:100468. [PMID: 35539429 PMCID: PMC9079235 DOI: 10.1016/j.xkme.2022.100468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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9
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Wu PH, Lin YT, Kuo MC, Liu JS, Tsai YC, Chiu YW, Carrero JJ. β-blocker dialyzability and the risk of mortality and cardiovascular events in patients undergoing hemodialysis. Nephrol Dial Transplant 2021; 35:1959-1965. [PMID: 32719861 DOI: 10.1093/ndt/gfaa058] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Accepted: 02/26/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND β-blocker (BB) dialyzability has been proposed to limit their efficacy among hemodialysis (HD) patients. We attempted to confirm this hypothesis by comparing health outcomes associated with the initiation of dialyzable or nondialyzable BBs in a nationwide cohort of HD patients. METHODS We created a prospective cohort study of 15 699 HD patients who initiated dialyzable BBs (atenolol, acebutolol, metoprolol and bisoprolol) and 20 904 hemodialysis patients who initiated nondialyzable BBs (betaxolol, carvedilol and propranolol) between 2004 and 2011 in Taiwan healthcare. We compared the risk of all-cause mortality and major adverse cardiovascular events (MACEs, a composite of the acute coronary syndrome, ischemic stroke and heart failure) between users of dialyzable versus nondialyzable BBs during a 2-year follow-up. RESULTS New users of dialyzable BBs were younger, more often men, with diabetes mellitus, hypertension and hyperlipidemia compared with users of nondialyzable BBs. Compared with nondialyzable BBs, initiation of dialyzable BBs was associated with lower all-cause mortality {hazard ratio [HR] 0.82 [95% confidence interval (CI) 0.75-0.88]} and lower risk of MACEs [HR 0.89 (95% CI 0.84-0.93)]. Results were confirmed in subgroup analyses, censoring at BB discontinuation or switch, after 1:1 propensity score matching, reclassifying bisoprolol or excluding bisoprolol/carvedilol users. CONCLUSIONS This study does not offer support for the hypothesis that the dialyzability of BBs reduces their efficacy in HD patients.
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Affiliation(s)
- Ping-Hsun Wu
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yi-Ting Lin
- Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Family Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Mei-Chuan Kuo
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Faculty of Renal Care, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Jia-Sin Liu
- Graduate Institute of Public Health, College of Health Science, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yi-Chun Tsai
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Faculty of Renal Care, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Division of General Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yi-Wen Chiu
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Faculty of Renal Care, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Juan-Jesus Carrero
- Department of Medical Epidemiology and Biostatistics (MEB), Karolinska Institutet, Stockholm, Sweden; Department of Medical Science, Uppsala University, Uppsala, Sweden
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Hundemer GL, Sood MM, Canney M. β-blockers in hemodialysis: simple questions, complicated answers. Clin Kidney J 2021; 14:731-734. [PMID: 33779640 PMCID: PMC7986367 DOI: 10.1093/ckj/sfaa249] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Indexed: 12/15/2022] Open
Abstract
In this issue of the Clinical Kidney Journal, Wu et al. present the results of a nationwide population-based study using Taiwanese administrative data to compare safety and efficacy outcomes with initiation of bisoprolol versus carvedilol among patients receiving maintenance hemodialysis for >90 days. The primary outcomes were all-cause mortality and major adverse cardiovascular events over 2 years of follow-up. The study found that bisoprolol was associated with a lower risk for both major adverse cardiovascular events and all-cause mortality compared with carvedilol. While the bulk of the existing evidence favors a cardioprotective and survival benefit with β-blockers as a medication class among dialysis patients, there is wide heterogeneity among specific β-blockers in regard to pharmacologic properties and dialyzability. While acknowledging the constraints of observational data, these findings may serve to inform clinicians about the preferred β-blocker agent for dialysis patients to help mitigate cardiovascular risk and improve long-term survival for this high-risk population.
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Affiliation(s)
- Gregory L Hundemer
- Department of Medicine, Division of Nephrology, The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Canada
| | - Manish M Sood
- Department of Medicine, Division of Nephrology, The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Canada
- Institute for Clinical Evaluative Sciences, Ottawa, Canada
| | - Mark Canney
- Department of Medicine, Division of Nephrology, The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Canada
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11
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Wu PH, Lin YT, Liu JS, Tsai YC, Kuo MC, Chiu YW, Hwang SJ, Carrero JJ. Comparative effectiveness of bisoprolol and carvedilol among patients receiving maintenance hemodialysis. Clin Kidney J 2021; 14:983-990. [PMID: 33779636 PMCID: PMC7986334 DOI: 10.1093/ckj/sfaa248] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Accepted: 10/26/2020] [Indexed: 01/11/2023] Open
Abstract
Background Despite widespread use, there is no trial evidence to inform β-blocker's (BB) relative safety and efficacy among patients undergoing hemodialysis (HD). We herein compare health outcomes associated with carvedilol or bisoprolol use, the most commonly prescribed BBs in these patients. Methods We created a cohort study of 9305 HD patients who initiated bisoprolol and 11 171 HD patients who initiated carvedilol treatment between 2004 and 2011. We compared the risk of all-cause mortality and major adverse cardiovascular events (MACEs) between carvedilol and bisoprolol users during a 2-year follow-up. Results Bisoprolol initiators were younger, had shorter dialysis vintage, were women, had common comorbidities of hypertension and hyperlipidemia and were receiving statins and antiplatelets, but they had less heart failure and digoxin prescriptions than carvedilol initiators. During our observations, 1555 deaths and 5167 MACEs were recorded. In the multivariable-adjusted Cox model, bisoprolol initiation was associated with a lower all-cause mortality {hazard ratio [HR] 0.66 [95% confidence interval (CI) 0.60-0.73]} compared with carvedilol initiation. After accounting for the competing risk of death, bisoprolol use (versus carvedilol) was associated with a lower risk of MACEs [HR 0.85 (95% CI 0.80-0.91)] and attributed to a lower risk of heart failure [HR 0.83 (95% CI 0.77-0.91)] and ischemic stroke [HR 0.84 (95% CI 0.72-0.97)], but not to differences in the risk of acute myocardial infarction [HR 1.03 (95% CI 0.93-1.15)]. Results were confirmed in propensity score matching analyses, stratified analyses and analyses that considered prescribed dosages or censored patients discontinuing or switching BBs. Conclusions Relative to carvedilol, bisoprolol initiation by HD patients was associated with a lower 2-year risk of death and MACEs, mainly attributed to lower heart failure and ischemic stroke risk.
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Affiliation(s)
- Ping-Hsun Wu
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yi-Ting Lin
- Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Family Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Jia-Sin Liu
- Graduate Institute of Public Health, College of Health Science, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yi-Chun Tsai
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Division of General Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,Faculty of Renal Care, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Mei-Chuan Kuo
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Faculty of Renal Care, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yi-Wen Chiu
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Faculty of Renal Care, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Shang-Jyh Hwang
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Faculty of Renal Care, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Institute of Population Sciences, National Health Research Institutes, Miaoli, Taiwan
| | - Juan-Jesus Carrero
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
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12
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Effects of renal denervation on blood pressure in hypertensive patients with end-stage renal disease: a single centre experience. Clin Exp Nephrol 2019; 23:749-755. [DOI: 10.1007/s10157-019-01697-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Accepted: 01/17/2019] [Indexed: 11/27/2022]
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13
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Aoun M, Tabbah R. Beta-blockers use from the general to the hemodialysis population. Nephrol Ther 2019; 15:71-76. [PMID: 30718084 DOI: 10.1016/j.nephro.2018.10.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2018] [Accepted: 10/01/2018] [Indexed: 01/02/2023]
Abstract
Beta-blockers have numerous indications in the general population and are strongly recommended in heart failure, post-myocardial infarction and arrhythmias. In hemodialysis patients, their use is based on weak evidence because of the lack of a sufficient number of randomized clinical trials. The strongest evidence is based on two trials. The first showed better survival with carvedilol in hemodialysis patients with four sessions per week and systolic heart failure. The second found reduced cardiovascular morbidity with atenolol compared to lisinopril in mostly black hypertensive hemodialysis patients. No clinical trials exist regarding myocardial infarction. Large retrospective studies have assessed the benefits of beta-blockers in hemodialysis. A large cohort of hemodialysis patients with new-onset heart failure showed better survival when treated with carvedilol, bisoprolol or metoprolol. Another recent one of 20,064 patients found out that metoprolol compared to carvedilol was associated with less all-cause mortality. There is still uncertainty also regarding the impact of dialysability of beta-blockers on patient's survival. On top of that, many observations suggested that beta-blockers were associated with a reduced rate of sudden cardiac death in hemodialysis patients but recent data show a link between bradycardia and sudden cardiac death questioning the benefit of beta-blockade in this population. Finally, what we know for sure so far is that beta-blockers should be avoided in patients with intradialytic hypotension associated with bradycardia.
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Affiliation(s)
- Mabel Aoun
- Department of nephrology, Saint-Georges Hospital, Saint-Joseph University, Damascus street, Beirut, Lebanon.
| | - Randa Tabbah
- Department of cardiology, Holy Spirit University, Kaslik, Lebanon
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14
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Hoye NA, Wilson LC, Jardine DL, Walker RJ. Sympathetic overactivity in dialysis patients-Underappreciated and clinically consequential. Semin Dial 2018; 32:255-265. [PMID: 30461070 DOI: 10.1111/sdi.12756] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Cardiovascular morbidity and mortality remain frustratingly common in dialysis patients. A dearth of established evidence-based treatment calls for alternative therapeutic avenues to be embraced. Sympathetic hyperactivity, predominantly due to afferent nerve signaling from the diseased native kidneys, has been established to be prognostic in the dialysis population for over 15 years. Despite this, tangible therapeutic interventions have, to date, been unsuccessful and the outlook for patients remains poor. This narrative review summarizes established experimental and clinical data, highlighting recent developments, and proposes why interventions to ameliorate sympathetic hyperactivity may well be beneficial for this high-risk population.
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Affiliation(s)
- Neil A Hoye
- Department of Renal Medicine, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - Luke C Wilson
- Department of Medicine, Dunedin School of Medicine, University of Otago, Dunedin, Otago, New Zealand
| | - David L Jardine
- Department of Medicine, University of Otago, Christchurch, Otago, New Zealand
| | - Robert J Walker
- Department of Medicine, Dunedin School of Medicine, University of Otago, Dunedin, Otago, New Zealand
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15
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Assimon MM, Brookhart MA, Fine JP, Heiss G, Layton JB, Flythe JE. A Comparative Study of Carvedilol Versus Metoprolol Initiation and 1-Year Mortality Among Individuals Receiving Maintenance Hemodialysis. Am J Kidney Dis 2018; 72:337-348. [PMID: 29653770 PMCID: PMC6477681 DOI: 10.1053/j.ajkd.2018.02.350] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Accepted: 02/04/2018] [Indexed: 11/11/2022]
Abstract
BACKGROUND Carvedilol and metoprolol are the β-blockers most commonly prescribed to US hemodialysis patients, accounting for ∼80% of β-blocker prescriptions. Despite well-established pharmacologic and pharmacokinetic differences between the 2 medications, little is known about their relative safety and efficacy in the hemodialysis population. STUDY DESIGN A retrospective cohort study using a new-user design. SETTING & PARTICIPANTS Medicare-enrolled hemodialysis patients treated at a large US dialysis organization who initiated carvedilol or metoprolol therapy from January 1, 2007, through December 30, 2012. PREDICTOR Carvedilol versus metoprolol initiation. OUTCOMES All-cause mortality, cardiovascular mortality, and intradialytic hypotension (systolic blood pressure decrease ≥ 20mmHg during hemodialysis plus intradialytic saline solution administration) during a 1-year follow-up period. MEASUREMENTS Survival models were used to estimate HRs and 95% CIs in mortality analyses. Poisson regression was used to estimate incidence rate ratios (IRRs) and 95% CIs in intradialytic hypotension analyses. Inverse probability of treatment weighting was used to adjust for several demographic, clinical, laboratory, and dialysis treatment covariates in all analyses. RESULTS 27,064 individuals receiving maintenance hemodialysis were included: 9,558 (35.3%) carvedilol initiators and 17,506 (64.7%) metoprolol initiators. Carvedilol (vs metoprolol) initiation was associated with greater all-cause (adjusted HR, 1.08; 95% CI, 1.02-1.16) and cardiovascular mortality (adjusted HR, 1.18; 95% CI, 1.08-1.29). In subgroup analyses, similar associations were observed among patients with hypertension, atrial fibrillation, heart failure, and a recent myocardial infarction, the main cardiovascular indications for β-blocker therapy. During follow-up, carvedilol (vs metoprolol) initiators had a higher rate of intradialytic hypotension (adjusted IRR, 1.10; 95% CI, 1.09-1.11). LIMITATIONS Residual confounding may exist. CONCLUSIONS Relative to metoprolol initiation, carvedilol initiation was associated with higher 1-year all-cause and cardiovascular mortality. One potential mechanism for these findings may be the increased occurrence of intradialytic hypotension after carvedilol (vs metoprolol) initiation.
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Affiliation(s)
- Magdalene M Assimon
- University of North Carolina Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, UNC School of Medicine, Chapel Hill, NC; Department of Epidemiology, UNC Gillings School of Global Public Health, Chapel Hill, NC.
| | - M Alan Brookhart
- Department of Epidemiology, UNC Gillings School of Global Public Health, Chapel Hill, NC
| | - Jason P Fine
- Department of Biostatistics, UNC Gillings School of Global Public Health, Chapel Hill, NC
| | - Gerardo Heiss
- Department of Epidemiology, UNC Gillings School of Global Public Health, Chapel Hill, NC
| | - J Bradley Layton
- Department of Epidemiology, UNC Gillings School of Global Public Health, Chapel Hill, NC; RTI Health Solutions, Research Triangle Park, Chapel Hill, NC
| | - Jennifer E Flythe
- University of North Carolina Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, UNC School of Medicine, Chapel Hill, NC; Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, NC
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16
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Vangala C, Winkelmayer WC. Heterogeneity in Outcomes Among β-Blockers Elucidated by Intradialytic Data. Am J Kidney Dis 2018; 72:318-321. [DOI: 10.1053/j.ajkd.2018.03.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Accepted: 03/28/2018] [Indexed: 11/11/2022]
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17
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Vanholder R, Van Laecke S, Glorieux G, Verbeke F, Castillo-Rodriguez E, Ortiz A. Deleting Death and Dialysis: Conservative Care of Cardio-Vascular Risk and Kidney Function Loss in Chronic Kidney Disease (CKD). Toxins (Basel) 2018; 10:E237. [PMID: 29895722 PMCID: PMC6024824 DOI: 10.3390/toxins10060237] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Accepted: 05/11/2018] [Indexed: 02/07/2023] Open
Abstract
The uremic syndrome, which is the clinical expression of chronic kidney disease (CKD), is a complex amalgam of accelerated aging and organ dysfunctions, whereby cardio-vascular disease plays a capital role. In this narrative review, we offer a summary of the current conservative (medical) treatment options for cardio-vascular and overall morbidity and mortality risk in CKD. Since the progression of CKD is also associated with a higher cardio-vascular risk, we summarize the interventions that may prevent the progression of CKD as well. We pay attention to established therapies, as well as to novel promising options. Approaches that have been considered are not limited to pharmacological approaches but take into account lifestyle measures and diet as well. We took as many randomized controlled hard endpoint outcome trials as possible into account, although observational studies and post hoc analyses were included where appropriate. We also considered health economic aspects. Based on this information, we constructed comprehensive tables summarizing the available therapeutic options and the number and kind of studies (controlled or not, contradictory outcomes or not) with regard to each approach. Our review underscores the scarcity of well-designed large controlled trials in CKD. Nevertheless, based on the controlled and observational data, a therapeutic algorithm can be developed for this complex and multifactorial condition. It is likely that interventions should be aimed at targeting several modifiable factors simultaneously.
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Affiliation(s)
- Raymond Vanholder
- Nephrology Section, Department of Internal Medicine, Ghent University Hospital, 9000 Ghent, Belgium.
| | - Steven Van Laecke
- Nephrology Section, Department of Internal Medicine, Ghent University Hospital, 9000 Ghent, Belgium.
| | - Griet Glorieux
- Nephrology Section, Department of Internal Medicine, Ghent University Hospital, 9000 Ghent, Belgium.
| | - Francis Verbeke
- Nephrology Section, Department of Internal Medicine, Ghent University Hospital, 9000 Ghent, Belgium.
| | | | - Alberto Ortiz
- Department of Nephrology and Hypertension, IIS-Fundacion Jimenez Diaz UAM, 28040 Madrid, Spain.
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18
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Schechtman SA, Wertz AP, Shanks A, Thompson A, Tremper K, Pynnonen MA, Healy DW. Preoperative β-blockade and hypertension in the first hour of functional endoscopic sinus surgery. Laryngoscope 2017; 127:1496-1505. [PMID: 28160292 DOI: 10.1002/lary.26492] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Revised: 12/01/2016] [Accepted: 12/20/2016] [Indexed: 11/06/2022]
Abstract
OBJECTIVES/HYPOTHESIS Local anesthetic with epinephrine is commonly injected into the nasal mucosa during functional endoscopic sinus surgery (FESS). Systemic absorption of epinephrine following local injection may occur, resulting in a mild sympathetic response. This study seeks to determine whether an exaggerated sympathetic response to epinephrine is demonstrated in patients undergoing FESS treated preoperatively with established pharmacologic beta (β) adrenoceptor blockade. STUDY DESIGN A retrospective analysis of adult patients undergoing FESS at a tertiary care university hospital. METHODS The primary outcome was the occurrence of an exaggerated hypertensive response within the first hour of surgical time defined by a relative increase (>20%) in the first measured intraoperative systolic blood pressure (SBP) prior to induction of anesthesia, or a single SBP value above 200 mm Hg. A mixed effects logistic regression model was developed to identify independent predictors of an exaggerated hypertensive response and describe the variance in the outcome attributable to the surgeon and anesthesiologist. RESULTS There were 2,051 patients identified. Independent predictors of an exaggerated intraoperative hypertensive event included: preoperative β-blocker use (adjusted odds ratio [AOR]: 3.33), female gender (AOR: 1.92), body mass index (AOR: 1.03), lower baseline SBP (AOR: 0.93), and advanced age (AOR: 1.03). The C statistic for the model was 0.8881. CONCLUSIONS Preoperative β-blocker use is an independent predictor of an exaggerated hypertensive response within the first hour of operative time. An exaggerated hypertensive effect should be anticipated in patients presenting for FESS with established pharmacologic β-blockade, and caution should be applied to use of epinephrine-containing solutions. LEVEL OF EVIDENCE 4. Laryngoscope, 127:1496-1505, 2017.
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Affiliation(s)
- Samuel A Schechtman
- Department of Anesthesiology, University of Michigan Health System, Ann Arbor, Michigan, U.S.A
| | - Aileen P Wertz
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan Health System, Ann Arbor, Michigan, U.S.A
| | - Amy Shanks
- Department of Anesthesiology, University of Michigan Health System, Ann Arbor, Michigan, U.S.A
| | - Aleda Thompson
- Department of Anesthesiology, University of Michigan Health System, Ann Arbor, Michigan, U.S.A
| | - Kevin Tremper
- Department of Anesthesiology, University of Michigan Health System, Ann Arbor, Michigan, U.S.A
| | - Melissa A Pynnonen
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan Health System, Ann Arbor, Michigan, U.S.A
| | - David W Healy
- Department of Anesthesiology, University of Michigan Health System, Ann Arbor, Michigan, U.S.A
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19
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Shireman TI, Mahnken JD, Phadnis MA, Ellerbeck EF, Wetmore JB. Comparative Effectiveness of Renin-Angiotensin System Antagonists in Maintenance Dialysis Patients. Kidney Blood Press Res 2016; 41:873-885. [PMID: 27871075 DOI: 10.1159/000452590] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/08/2016] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND/AIMS Whether angiotensin converting enzyme inhibitors (ACE) and angiotensin receptor blockers (ARB) are differentially associated with reductions in cardiovascular events and mortality in patients receiving maintenance dialysis is uncertain. We compared outcomes between ACE and ARB users among hypertensive, maintenance dialysis patients. METHODS National retrospective cohort study of hypertensive, Medicare-Medicaid eligible patients initiating chronic dialysis between 1/1/2000 to 12/31/2005. The exposure of interest was new use of either an ACEI or ARB. Outcomes were all-cause mortality (ACM) and combined cardiovascular hospitalization or death (CV-endpoint). Cox proportion hazards models were used to compare the effect of ACEI vs ARB use on ACM and, separately, CV-endpoint. RESULTS ACM models were based on 3,555 ACEI and 1,442 ARB new users, while CV-endpoint models included 3,289 ACEI and 1,346 ARB new users. After statistical adjustments, ACEI users had higher hazard ratios for ACM (AHR = 1.22, 99% CI 1.05-1.42) and CV-endpoint (AHR = 1.12, 99% CI 0.99-1.27). CONCLUSIONS Patients initiating maintenance dialysis who received an ACEI faced an increased risk for mortality and a trend towards an increased risk for CV-endpoints when compared to patients who received an ARB. Validation of these results in a rigorous clinical trial is warranted.
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Affiliation(s)
- Theresa I Shireman
- Center for Gerontology & Health Care Research, Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI, USA
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