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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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Marti HP, Pavía López AA, Schwartzmann P. Safety and tolerability of β-blockers: importance of cardioselectivity. Curr Med Res Opin 2024; 40:55-62. [PMID: 38597063 DOI: 10.1080/03007995.2024.2317433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 02/02/2024] [Indexed: 04/11/2024]
Abstract
Cardioselective β-blockade is generally well tolerated in practice and contraindications to this therapy are uncommon. β-blockers are a diverse therapeutic class, and their individual tolerability profiles are influenced strongly by their pharmacodynamic effects across different adrenergic receptors. Bisoprolol, probably the β-blocker with the highest selectivity for blockade of β1- vs. β2-adrenoceptors, does not block β2-adrenoceptors to an appreciable extent at doses in therapeutic use. Side-effects often attributed to β-blockers, such as erectile dysfunction and adverse metabolic effects are uncommon with bisoprolol and other β-blockers used at doses which only block β1-adrenoceptors. Cautious use of a cardioselective β-blocker is not contraindicated in people with chronic obstructive pulmonary disease or asthma and the outcomes benefits of β-blockers in patients with coronary heart disease or heart failure are also apparent in patients with concurrent COPD. Starting with a low dose and titrating upwards carefully is important for optimising the tolerability of a β-blocker. Most people with hypertension will receive combination antihypertensive therapy in practice, and the low-dose combination therapy approach provides a useful strategy for optimising the efficacy and tolerability of a regimen that includes a β-blocker, compared with up-titrating an existing monotherapy.
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Affiliation(s)
- Hans-Peter Marti
- Nephrology Section, Department of Medicine, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | | | - Pedro Schwartzmann
- Advanced Research Center - CAPED, Cardiology Unit, Unimed Hospital, Ribeirão Preto, Brazil
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3
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Taddei S, Tsabedze N, Tan RS. β-blockers are not all the same: pharmacologic similarities and differences, potential combinations and clinical implications. Curr Med Res Opin 2024; 40:15-23. [PMID: 38597065 DOI: 10.1080/03007995.2024.2318058] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 02/07/2024] [Indexed: 04/11/2024]
Abstract
β-blockers are a heterogeneous class, with individual agents distinguished by selectivity for β1- vs. β2- and α-adrenoceptors, presence or absence of partial agonist activity at one of more β-receptor subtype, presence or absence of additional vasodilatory properties, and lipophilicity, which determines the ease of entry the drug into the central nervous system. Cardioselectivity (β1-adrenoceptor selectivity) helps to reduce the potential for adverse effects mediated by blockade of β2-adrenoceptors outside the myocardium, such as cold extremities, erectile dysfunction, or exacerbation of asthma or chronic obstructive pulmonary disease. According to recently updated guidelines from the European Society of Hypertension, β-blockers are included within the five major drug classes recommended as the basis of antihypertensive treatment strategies. Adding a β-blocker to another agent with a complementary mechanism may provide a rational antihypertensive combination that minimizes the adverse impact of induced sympathetic overactivity for optimal blood pressure-lowering efficacy and clinical outcomes benefit.
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Affiliation(s)
- Stefano Taddei
- Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Nqoba Tsabedze
- Division of Cardiology, Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Ru-San Tan
- Department of Cardiology, National Heart Centre Singapore, Singapore
- Cardiovascular Sciences, Duke NUS Medical School, Singapore
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Gomes RVC, Peluso AA, Ronchi FA, de Oliveira LCG, Casarini DE, Santos RAS, Endlich PW, de Abreu GR. Antihypertensive treatment of end-stage renal disease patients on hemodialysis does not alter circulating ACE and ACE2 activity and angiotensin peptides. Am J Med Sci 2024; 367:128-134. [PMID: 37984736 DOI: 10.1016/j.amjms.2023.11.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 07/08/2023] [Accepted: 11/16/2023] [Indexed: 11/22/2023]
Abstract
Cardiovascular diseases (CVD) are the main causes of death in hemodialysis patients, representing a public health challenge. We investigated the effect of different antihypertensive treatments on circulating levels of renin-angiotensin system (RAS) components in end-stage renal disease (ESRD) patients on hemodialysis. ESRD patients were grouped following the prescribed antihypertensive drugs: ß-blocker, ß-blocker+ACEi and ß-blocker+AT1R blocker. ESDR patients under no antihypertensive drug treatment were used as controls. Blood samples were collected before hemodialysis sessions. Enzymatic activities of the angiotensin-converting enzymes ACE and ACE2 were measured through fluorescence assays and plasma concentrations of the peptides Angiotensin II (Ang II) and Angiotensin-(1-7) [Ang-(1-7)] were quantified using mass spectrometry (LC-MS/MS). ACE activity was decreased only in the ß-blocker+ACEi group compared to the ß-blocker+AT1R, while ACE2 activity did not change according to the antihypertensive treatment. Both Ang II and Ang-(1-7) levels also did not change according to the antihypertensive treatment. We concluded that the treatment of ESRD patients on hemodialysis with different antihypertensive drugs do not alter the circulating levels of RAS components.
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Affiliation(s)
- Renata Vitoriano Corradi Gomes
- Mucuri's Medical School, Multicentric Post-Graduate Program in Physiological Sciences and Health Sciences Post-Graduate Program, Federal University of the Jequitinhonha and Mucuri Valleys, Teófilo Otoni-MG, Brazil
| | - A Augusto Peluso
- Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
| | | | | | - Dulce Elena Casarini
- Department of Medicine, Federal University of São Paulo (UNIFESP), São Paulo-SP, Brazil
| | | | - Patrick Wander Endlich
- Mucuri's Medical School, Multicentric Post-Graduate Program in Physiological Sciences and Health Sciences Post-Graduate Program, Federal University of the Jequitinhonha and Mucuri Valleys, Teófilo Otoni-MG, Brazil.
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Ray S, Nair T, Sawhney J, Erwinanto, Rosman A, Reyes E, Go L, Sukonthasarn A, Ariyachaipanich A, Hung PM, Chaudhari H, Malhi HS. Role of β-blockers in the cardiovascular disease continuum: a collaborative Delphi survey-based consensus from Asia-Pacific. Curr Med Res Opin 2023; 39:1671-1683. [PMID: 37694536 DOI: 10.1080/03007995.2023.2256218] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 08/28/2023] [Accepted: 09/04/2023] [Indexed: 09/12/2023]
Abstract
OBJECTIVE This Delphi method of consensus was designed to develop scientific statements for β-blockers in the continuum of cardiovascular diseases with a special focus on the role of bisoprolol. METHODS Eleven experienced cardiologists from across the Asia-Pacific countries participated in two rounds of the survey. In the first round, experts were asked to rate agreement/disagreement with 35 statements across seven domains regarding the use of β-blockers for treating hypertension, heart failure, coronary artery diseases, co-morbidities, as well as their safety profile, usage pattern, and pharmacokinetic variability. A consensus for a statement could be reached with >70% agreement. RESULTS Except for seven statements, all attained consensus in the first round. In the second round that was conducted virtually, the experts re-appraised their ratings for the seven statements along with a critical appraisal of two additional statements that were suggested by experts in the preceding round. At the end of the second round, the final version included 36 statements (34 original statements, two statements suggested by experts, and the omission of one statement that did not attain consensus). The final version of statements in the second round was disseminated among experts for their approval followed by manuscript development. CONCLUSION Attainment of consensus for almost all statements reconfirms the clinical benefits of β-blockers, particularly β1-selective blockers for the entire spectrum of cardiovascular diseases.
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Affiliation(s)
- Saumitra Ray
- Department of Cardiology, AMRI Hospital (S), West Bengal, Kolkata, India
| | - Tiny Nair
- Department of Cardiology, PRS Hospital, Trivandrum, Kerala, India
| | - Jps Sawhney
- Department of Cardiology, Member Board of Management at Sir Ganga Ram Hospital, New Delhi, India
| | - Erwinanto
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Padjajaran University, Jawa Barat, Indonesia
| | | | - Eugene Reyes
- Section of Cardiology, Department of Internal Medicine, UP-Philippine General Hospital, Manila, Philippines
| | - Loewe Go
- Internal Medicine - Cardiology, St. Luke's Medical Center, Taguig, Philippines
| | | | - Aekarach Ariyachaipanich
- Division of Cardiovascular Medicine, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Phạm Manh Hung
- National Heart Institute, Bach Mai Hospital, Hanoi, Vietnam
| | - Harshal Chaudhari
- Merck Specialities Pvt. Ltd., India, an affiliate of Merck KGaA, Darmstadt, Germany
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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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8
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Hameed K, Chinnam S, Khan KS, Mushtaq S, Ahmad N, Jaber AAS, Anwar Z, Ur-Rehman I, Khan A. Evaluation of hypertension control among hemodialysis patients in Pakistan: a prospective follow-up study. Blood Press Monit 2023; 28:253-259. [PMID: 37409474 DOI: 10.1097/mbp.0000000000000656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/07/2023]
Abstract
BACKGROUND Hypertension is highly prevalent and uncontrolled among hemodialysis patients. In Pakistan published data does not provide enough information about the management and factors associated with uncontrolled hypertension in hemodialysis patients. OBJECTIVE This study was conducted to evaluate the factors influencing the pharmacotherapeutic management and control of hypertension in hemodialysis patients. METHODS A prospective follow-up study was conducted on hemodialysis patients who were enrolled at study sites between 1 June 2020 and 31 December 2020. The predialysis blood pressure (BP) readings were recorded as mean SBP and DBP at baseline and for each of 6 months. Multivariate analyses were applied to analyze the factors associated with uncontrolled hypertension in hemodialysis patients. RESULTS The average predialysis BP (SBP and DBP) of study participants at baseline visit was 158.41 and 87.22 mmHg respectively. After 6 months the study participants have 150.27 mmHg and 80.03 mmHg average predialysis SBP and DBP respectively. Only 28.1% of hemodialysis patients were on target BP after 6 months. Results of multivariate analysis have shown that the use of beta-blockers and calcium channel blockers (CCBs) were significantly associated with hypertension control at baseline [odds ratio (OR) = 1.432, P value = 0.034] (OR = 1.499, P value = 0.045) and at after 6 months (OR = 2.824, P value = 0.015) (OR = 1.883, P value = 0.032). CONCLUSION This study revealed that among the antihypertensive drugs, CCBs and beta-blockers provided better management in controlling hypertension among hemodialysis patients.
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Affiliation(s)
- Kiran Hameed
- Department of Pharmacy, Quaid-i-Azam University, Islamabad, Pakistan
| | - Sampath Chinnam
- Department of Chemistry, M.S. Ramaiah Institute of Technology (affiliated to Visvesvaraya Technological University, Belgaum), Bengaluru, Karnataka, India
| | | | - Saima Mushtaq
- Department of Healthcare Biotechnology, Atta-ur-Rahman School of Applied Biosciences, National University of Sciences and Technology, Islamabad
| | - Nafees Ahmad
- Department of Pharmacy Practice, Faculty of Pharmacy and Health Sciences, University of Balochistan, Quetta, Pakistan
| | - Ammar Ali Saleh Jaber
- Department of Clinical Pharmacy & Pharmacotherapeutics, Dubai Pharmacy College for Girls, AlMuhaisanah 1, Al mizhar Dubai, UAE
| | - Zeeshan Anwar
- Department of Pharmacy, Abdul Wali Khan University, Mardan, Pakistan
| | - Inayat Ur-Rehman
- Department of Pharmacy, Abdul Wali Khan University, Mardan, Pakistan
| | - Amjad Khan
- Department of Pharmacy, Quaid-i-Azam University, Islamabad, Pakistan
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Kim IS, Kim S, Yoo TH, Kim JK. Diagnosis and treatment of hypertension in dialysis patients: a systematic review. Clin Hypertens 2023; 29:24. [PMID: 37653470 PMCID: PMC10472689 DOI: 10.1186/s40885-023-00240-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Accepted: 05/24/2023] [Indexed: 09/02/2023] Open
Abstract
In patients with end-stage renal disease (ESRD) undergoing dialysis, hypertension is common but often inadequately controlled. The prevalence of hypertension varies widely among studies because of differences in the definition of hypertension and the methods of used to measure blood pressure (BP), i.e., peri-dialysis or ambulatory BP monitoring (ABPM). Recently, ABPM has become the gold standard for diagnosing hypertension in dialysis patients. Home BP monitoring can also be a good alternative to ABPM, emphasizing BP measurement outside the hemodialysis (HD) unit. One thing for sure is pre- and post-dialysis BP measurements should not be used alone to diagnose and manage hypertension in dialysis patients. The exact target of BP and the relationship between BP and all-cause mortality or cause-specific mortality are unclear in this population. Many observational studies with HD cohorts have almost universally reported a U-shaped or even an L-shaped association between BP and all-cause mortality, but most of these data are based on the BP measured in HD units. Some data with ABPM have shown a linear association between BP and mortality even in HD patients, similar to the general population. Supporting this, the results of meta-analysis have shown a clear benefit of BP reduction in HD patients. Therefore, further research is needed to determine the optimal target BP in the dialysis population, and for now, an individualized approach is appropriate, with particular emphasis on avoiding excessively low BP. Maintaining euvolemia is of paramount importance for BP control in dialysis patients. Patient heterogeneity and the lack of comparative evidence preclude the recommendation of one class of medication over another for all patients. Recently, however, β-blockers could be considered as a first-line therapy in dialysis patients, as they can reduce sympathetic overactivity and left ventricular hypertrophy, which contribute to the high incidence of arrhythmias and sudden cardiac death. Several studies with mineralocorticoid receptor antagonists have also reported promising results in reducing mortality in dialysis patients. However, safety issues such as hyperkalemia or hypotension should be further evaluated before their use.
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Affiliation(s)
- In Soo Kim
- Department of Internal Medicine & Kidney Research Institute, Hallym University Sacred Heart Hospital, Pyungan-dong, Dongan-gu, Anyang, 431-070, Korea
| | - Sungmin Kim
- Department of Internal Medicine & Kidney Research Institute, Hallym University Sacred Heart Hospital, Pyungan-dong, Dongan-gu, Anyang, 431-070, Korea
| | - Tae-Hyun Yoo
- Department of Internal Medicine, College of Medicine, Institute of Kidney Disease Research, Yonsei University, Seoul, Korea
| | - Jwa-Kyung Kim
- Department of Internal Medicine & Kidney Research Institute, Hallym University Sacred Heart Hospital, Pyungan-dong, Dongan-gu, Anyang, 431-070, Korea.
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10
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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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Abstract
Patients with chronic kidney disease (CKD) are at high risk to develop cardiovascular disease with its manifestations coronary artery disease, heart failure, arrhythmias, and sudden cardiac death. In addition, the presence of CKD has a major impact on the prognosis of patients with cardiovascular disease, leading to an increased morbidity and mortality if both comorbidities are present. Therapeutic options including medical therapy and interventional treatment are often limited in patients with advanced CKD, and in most cardiovascular outcome trials, patients with advanced CKD have been excluded. Thus, in many patients, treatment strategies for cardiovascular disease need to be extrapolated from trials conducted in patients without CKD. The current article summarizes the epidemiology, clinical presentation, and treatment options for the most prevalent manifestations of cardiovascular disease in CKD and discusses the currently available treatment options to reduce morbidity and mortality in this high-risk population.
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Affiliation(s)
- Katharina Schuett
- Department of Internal Medicine I (Cardiology), University Hospital, RWTH Aachen University, Germany
| | - Nikolaus Marx
- Department of Internal Medicine I (Cardiology), University Hospital, RWTH Aachen University, Germany
| | - Michael Lehrke
- Department of Internal Medicine I (Cardiology), University Hospital, RWTH Aachen University, Germany
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12
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Khan MS, Ahmed A, Greene SJ, Fiuzat M, Kittleson MM, Butler J, Bakris GL, Fonarow GC. Managing Heart Failure in Patients on Dialysis: State-of-the-Art Review. J Card Fail 2023; 29:87-107. [PMID: 36243339 DOI: 10.1016/j.cardfail.2022.09.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Revised: 08/28/2022] [Accepted: 09/20/2022] [Indexed: 11/07/2022]
Abstract
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.
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Affiliation(s)
| | - Aymen Ahmed
- Division of Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Stephen J Greene
- Division of Cardiology, Duke University School of Medicine, Durham, NC, USA; Duke Clinical Research Institute, Durham, NC, USA
| | - Mona Fiuzat
- Division of Cardiology, Duke University School of Medicine, Durham, NC, USA
| | - Michelle M Kittleson
- Department of Cardiology, Smidt Heart Institute-Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA; Baylor Scott and White Research Institute, Dallas, TX, USA
| | - George L Bakris
- Department of Medicine, University of Chicago Medicine, Chicago, IL
| | - Gregg C Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA.
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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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14
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Muacevic A, Adler JR, Dhrolia M, Nasir K, Ahmad A. Frequency of Intradialytic Hypertension Using Kidney Disease: Improving Global Outcomes (KDIGO) Suggested Definition in a Single Hemodialysis Centre in Pakistan. Cureus 2022; 14:e33104. [PMID: 36726901 PMCID: PMC9884737 DOI: 10.7759/cureus.33104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/28/2022] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVES To estimate the frequency of intradialytic hypertension (IDH) in our centre as per the definition suggested by Kidney Disease: Improving Global Outcomes (KDIGO). METHODS A cross-sectional study was conducted at the dialysis department of The Kidney Centre Post Graduate Training Institute (PGTI) Karachi, Pakistan from August 2021 to October 2021 among 263 end-stage kidney disease (ESKD) patients on maintenance hemodialysis (MHD) aged ≥ 18 years of both genders. The study outcome was the frequency of IDH as per the latest KDIGO suggested definition i.e., systolic blood pressure (SBP) rise of > 10 mm Hg from pre- to post-dialysis within the hypertensive range in at least four out of six consecutive dialysis treatments. Frequencies (%) and mean (±SD) were calculated for categorical and continuous variables respectively, using SPSS version 21 (IBM Corp., Armonk, NY, USA). RESULTS Among 263 patients, the mean age was 51.02 (±14.1) years and 56.3% were males. Around 30.8% of patients were dialysis-dependent for 1.1 to three years. The most common comorbidity was hypertension (88.6%). Standard dialysate calcium of 3mEq/l was received by 91.6% of study participants. About 78.7% of patients were using antihypertensive(s), out of which 85.5% were compliant and 37.6% were using a single antihypertensive. The most common antihypertensive in use was beta-blockers (78.3%). Around 16% of patients were found to have IDH. Age of the patients was significantly associated with IDH (p=0.038). The majority of the patients with IDH were those who were taking anti-hypertension medications as compared to the patients who were not taking them (p <0.004). Interdialytic weight gain was not a significant predictor for IDH. CONCLUSION The frequency of IDH was 16% according to the latest suggested KDIGO definition. This is much lower than regional and global estimates according to earlier definitions. There is a dire need to establish a standardized definition of IDH in guidelines to diagnose, manage and compare data. Also, the association of IDH with fluid overload is not found in our study which emphasizes the need to evaluate other causative factors.
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15
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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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16
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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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17
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Albakr RB, Bargman JM. A Comparison of Hemodialysis and Peritoneal Dialysis in Patients with Cardiovascular Disease. Cardiol Clin 2021; 39:447-453. [PMID: 34247757 DOI: 10.1016/j.ccl.2021.04.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The high prevalence of cardiovascular disease is caused by the traditional cardiovascular risk factors common among end-stage renal disease patients, and nontraditional risk factors attributed to underlying kidney disease, including chronic inflammation, anemia, bone mineral disease, and the dialysis procedure itself. Individualization of the treatment of cardiovascular disease in end-stage renal disease that could impact the underlying mechanisms of the cardiovascular diseases is important to improve outcomes. This article reviews and compares hemodialysis and peritoneal dialysis in association with different cardiovascular diseases affecting dialysis patients, including hypertension, coronary artery disease, myocardial stunning, cardiac arrhythmias, heart failure, and the cardiorenal syndrome.
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Affiliation(s)
- Rehab B Albakr
- Division of Nephrology, University of Toronto, University Health Network, 200 Elizabeth Street 8N-840, Toronto, ON M5G 2C4, Canada; Division of Nephrology, College of Medicine, King Saud University, King Khalid Street, Riyadh-Al-Diriyah 12372, Saudi Arabia
| | - Joanne M Bargman
- Division of Nephrology, University of Toronto, University Health Network/Toronto General Hospital, 200 Elizabeth Street, 8N-840, Toronto, Ontario M5G 2C4, Canada.
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18
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Chan K, Moe SM, Saran R, Libby P. The cardiovascular-dialysis nexus: the transition to dialysis is a treacherous time for the heart. Eur Heart J 2021; 42:1244-1253. [PMID: 33458768 DOI: 10.1093/eurheartj/ehaa1049] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Revised: 08/13/2020] [Accepted: 12/15/2020] [Indexed: 02/06/2023] Open
Abstract
Chronic kidney disease (CKD) patients require dialysis to manage the progressive complications of uraemia. Yet, many physicians and patients do not recognize that dialysis initiation, although often necessary, subjects patients to substantial risk for cardiovascular (CV) death. While most recognize CV mortality risk approximately doubles with CKD the new data presented here show that this risk spikes to >20 times higher than the US population average at the initiation of chronic renal replacement therapy, and this elevated CV risk continues through the first 4 months of dialysis. Moreover, this peak reflects how dialysis itself changes the pathophysiology of CV disease and transforms its presentation, progression, and prognosis. This article reviews how dialysis initiation modifies the interpretation of circulating biomarkers, alters the accuracy of CV imaging, and worsens prognosis. We advocate a multidisciplinary approach and outline the issues practitioners should consider to optimize CV care for this unique and vulnerable population during a perilous passage.
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Affiliation(s)
- Kevin Chan
- National Institute of Diabetes and Digestive and Kidney Disease, Division of Kidney, Urology, and Hematology, 6707 Democracy Blvd, Bethesda, MD 20892-5458, USA
| | - Sharon M Moe
- Division of Nephrology, Indiana University School of Medicine, 950 W. Walnut Street R2-202, Indianapolis, IN 46202, USA
| | - Rajiv Saran
- Division of Nephrology, Department of Internal Medicine, University of Michigan, 1500 E Medical Center Dr # 31, Ann Arbor, MI 48109, USA
| | - Peter Libby
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, 77 Ave. Louis Pasteur, NRB-741-G, Boston, MA 02115, USA
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19
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Fu EL, van Diepen M, Xu Y, Trevisan M, Dekker FW, Zoccali C, Jager K, Carrero JJ. Pharmacoepidemiology for nephrologists (part 2): potential biases and how to overcome them. Clin Kidney J 2021; 14:1317-1326. [PMID: 33959262 PMCID: PMC8087121 DOI: 10.1093/ckj/sfaa242] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 10/02/2020] [Indexed: 12/21/2022] Open
Abstract
Observational pharmacoepidemiological studies using routinely collected healthcare data are increasingly being used in the field of nephrology to answer questions on the effectiveness and safety of medications. This review discusses a number of biases that may arise in such studies and proposes solutions to minimize them during the design or statistical analysis phase. We first describe designs to handle confounding by indication (e.g. active comparator design) and methods to investigate the influence of unmeasured confounding, such as the E-value, the use of negative control outcomes and control cohorts. We next discuss prevalent user and immortal time biases in pharmacoepidemiology research and how these can be prevented by focussing on incident users and applying either landmarking, using a time-varying exposure, or the cloning, censoring and weighting method. Lastly, we briefly discuss the common issues with missing data and misclassification bias. When these biases are properly accounted for, pharmacoepidemiological observational studies can provide valuable information for clinical practice.
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Affiliation(s)
- Edouard L Fu
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Merel van Diepen
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Yang Xu
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Solna, Sweden
| | - Marco Trevisan
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Solna, Sweden
| | - Friedo W Dekker
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Carmine Zoccali
- CNR-IFC, Clinical Epidemiology of Renal Diseases and Hypertension, Reggio Calabria, Italy
| | - Kitty Jager
- Department of Medical Informatics, ERA-EDTA Registry, Amsterdam University Medical Center, Amsterdam Public Health Research Institute, University of Amsterdam, Amsterdam, The Netherlands
| | - Juan Jesus Carrero
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Solna, Sweden
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20
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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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21
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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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22
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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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23
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Chandra A, Rao N, Srivastava D, Mishra P. Better peridialytic blood pressure control using carvedilol in end stage renal disease patients on twice weekly maintenance hemodialysis. Int Urol Nephrol 2021; 53:1007-1014. [PMID: 33387227 DOI: 10.1007/s11255-020-02716-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Accepted: 11/05/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND While use of carvedilol in patients on hemodialysis is encouraged with its low dialyzability, evidence supporting its superiority over metoprolol in improving the blood pressure control during dialysis is lacking. This study was undertaken to study the blood pressure variations in the peridialytic period after conversion from metoprolol to carvedilol. MATERIALS AND METHODS In this this prospective, pre-post intervention study, patients on metoprolol were converted to carvedilol. Patients aged 18-65 years on biweekly dialysis with intradialytic rise in blood pressure {difference between pre- and post-dialysis systolic blood pressure > 10 mmHg with post-dialysis blood pressure of ≥ 130/80 mmHg} were recruited. The recorded blood pressure data post conversion to carvedilol was compared to the retrospective mean blood pressure recordings during metoprolol use. RESULTS Of the 48 subjects, the study mostly comprised young males (n-34, mean age- 37.06 ± 14.32 years). Both systolic and diastolic blood pressures at different time periods (pre-dialysis, intradialytic and post-dialysis) were significantly lower with carvedilol use than with metoprolol, p < 0.001. Mean pre-dialysis systolic blood pressures and diastolic blood pressures were 140.54 ± 7.68 and 84.42 ± 7.78 mmHg on carvedilol as compared to 148.12 ± 7.17 and 91.17 ± 6.97 mmHg on metoprolol (p < 0.001). Post-dialysis systolic blood pressures and diastolic blood pressures during Carvedilol regimen were better controlled at 147.42 ± 12.89 and 86.29 ± 7.31 mmHg, than 159.12 ± 8.18 and 97 ± 6.76 mmHg during metoprolol regimen (p < 0.001). CONCLUSION Our study has brought into focus the younger population at risk of peridialytic hypertension. Switch from metoprolol to carvedilol is an effective anti-hypertensive strategy in dialysis patients with poorly controlled peridialytic blood pressures. Carvedilol was well tolerated.
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Affiliation(s)
- Abhilash Chandra
- Department of Nephrology, Dr.RMLIMS, Vibhuti Khand, Gomti Nagar, Lucknow, 226010, India
| | - Namrata Rao
- Department of Nephrology, Dr.RMLIMS, Vibhuti Khand, Gomti Nagar, Lucknow, 226010, India.
| | - Divya Srivastava
- Department of Anaesthesiology, SGPGIMS, Rae Bareli Road, Lucknow, 226014, India
| | - Prabhaker Mishra
- Department of Biostatistics and Health Informatics, SGPGIMS, Rae Bareli Road, Lucknow, 226014, India
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24
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Zhou H, Sim JJ, Shi J, Shaw SF, Lee MS, Neyer JR, Kovesdy CP, Kalantar-Zadeh K, Jacobsen SJ. β-Blocker Use and Risk of Mortality in Heart Failure Patients Initiating Maintenance Dialysis. Am J Kidney Dis 2020; 77:704-712. [PMID: 33010357 DOI: 10.1053/j.ajkd.2020.07.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 07/12/2020] [Indexed: 11/11/2022]
Abstract
RATIONAL & OBJECTIVE Beta-blockers are recommended for patients with heart failure (HF) but their benefit in the dialysis population is uncertain. Beta-blockers are heterogeneous, including with respect to their removal by hemodialysis. We sought to evaluate whether β-blocker use and their dialyzability characteristics were associated with early mortality among patients with chronic kidney disease with HF who transitioned to dialysis. STUDY DESIGN Retrospective cohort study. SETTING & PARTICIPANTS Adults patients with chronic kidney disease (aged≥18 years) and HF who initiated either hemodialysis or peritoneal dialysis during January 1, 2007, to June 30, 2016, within an integrated health system were included. EXPOSURES Patients were considered treated with β-blockers if they had a quantity of drug dispensed covering the dialysis transition date. OUTCOMES All-cause mortality within 6 months and 1 year or hospitalization within 6 months after transition to maintenance dialysis. ANALYTICAL APPROACH Inverse probability of treatment weights using propensity scores was used to balance covariates between treatment groups. Cox proportional hazard analysis and logistic regression were used to investigate the association between β-blocker use and study outcomes. RESULTS 3,503 patients were included in the study. There were 2,115 (60.4%) patients using β-blockers at transition. Compared with nonusers, the HR for all-cause mortality within 6 months was 0.79 (95% CI, 0.65-0.94) among users of any β-blocker and 0.68 (95% CI, 0.53-0.88) among users of metoprolol at transition. There were no observed differences in all-cause or cardiovascular-related hospitalization. LIMITATIONS The observational nature of our study could not fully account for residual confounding. CONCLUSIONS Beta-blockers were associated with a lower rate of mortality among incident hemodialysis patients with HF. Similar associations were not observed for hospitalizations within the first 6 months following transition to dialysis.
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Affiliation(s)
- Hui Zhou
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA.
| | - John J Sim
- Division of Nephrology and Hypertension, Kaiser Permanente Los Angeles Medical Center. Los Angeles, CA.
| | - Jiaxiao Shi
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Sally F Shaw
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Ming-Sum Lee
- Division of Cardiology, Kaiser Permanente Los Angeles Medical Center. Los Angeles, CA
| | - Jonathan R Neyer
- Division of Cardiology, Kaiser Permanente Los Angeles Medical Center. Los Angeles, CA
| | - Csaba P Kovesdy
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN
| | - Kamyar Kalantar-Zadeh
- Division of Nephrology and Hypertension, University of California Irvine Medical Center, Irvine, CA
| | - Steven J Jacobsen
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
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25
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Shaman AM, Smyth B, Arnott C, Palmer SC, Mihailidou AS, Jardine MJ, Gallagher MP, Perkovic V, Jun M. Comparative Efficacy and Safety of BP-Lowering Pharmacotherapy in Patients Undergoing Maintenance Dialysis: A Network Meta-Analysis of Randomized, Controlled Trials. Clin J Am Soc Nephrol 2020; 15:1129-1138. [PMID: 32675281 PMCID: PMC7409758 DOI: 10.2215/cjn.12201019] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Accepted: 05/07/2020] [Indexed: 01/24/2023]
Abstract
BACKGROUND AND OBJECTIVES Elevated BP is an important risk factor for cardiovascular disease, with a prevalence of over 80% in patients undergoing maintenance dialysis. We assessed the comparative BP-lowering efficacy and the safety of BP-lowering drugs in patients undergoing maintenance dialysis. DESIGN, SETTINGS, PARTICIPANTS, & MEASUREMENTS We performed a frequentist random effects network meta-analysis of randomized, controlled trials evaluating BP-lowering agents in adult patients undergoing maintenance dialysis. Electronic databases (CENTRAL, MEDLINE, and Embase) were systematically searched (up to August 2018) for relevant trials. The main outcome was systolic BP reduction. RESULTS Forty trials (4283 participants) met our inclusion criteria. Angiotensin-converting enzyme inhibitors, β-blockers, calcium-channel blockers, and aldosterone antagonists lowered systolic BP to a greater extent than placebo, with effect sizes ranging from -10.8 mm Hg (95% confidence interval, -14.8 to -6.7 mm Hg) for the aldosterone antagonists to -4.3 mm Hg (95% confidence interval, -7.2 to -1.5 mm Hg) for angiotensin-converting enzyme inhibitors. Aldosterone antagonists and β-blockers were superior to angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, calcium-channel blockers, and renin inhibitors at lowering systolic BP. Compared with angiotensin-converting enzyme inhibitors, aldosterone antagonists and β-blockers lowered systolic BP by 6.4 mm Hg (95% confidence interval, -11.4 to -1.4 mm Hg) and 4.4 mm Hg (95% confidence interval, -7.4 to -1.3 mm Hg), respectively. Systolic BP reduction was not different with angiotensin receptor blockers, α-blockers, and calcium-channel blockers compared with angiotensin-converting enzyme inhibitors. Renin inhibitors were less effective. Angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and aldosterone antagonists incurred risks of drug discontinuation due to adverse events and hypotension. CONCLUSIONS BP-lowering agents significantly reduced systolic BP in patients undergoing maintenance dialysis. β-Blockers and aldosterone antagonists may confer larger reductions, although treatment with aldosterone antagonists may be limited by adverse events.
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Affiliation(s)
- Ahmed M Shaman
- The George Institute for Global Health, Faculty of Medicine, The University of New South Wales, Sydney, New South Wales, Australia.,Medication Safety Research Chair, Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Brendan Smyth
- The George Institute for Global Health, Faculty of Medicine, The University of New South Wales, Sydney, New South Wales, Australia.,Sydney School of Public Health, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Clare Arnott
- The George Institute for Global Health, Faculty of Medicine, The University of New South Wales, Sydney, New South Wales, Australia.,Department of Cardiology, The Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Suetonia C Palmer
- Department of Medicine, University of Otago Christchurch, Christchurch, New Zealand
| | - Anastasia S Mihailidou
- Department of Cardiology and Kolling Institute, Northern Sydney Local Health District, St. Leonards, New South Wales, Australia.,Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Meg J Jardine
- The George Institute for Global Health, Faculty of Medicine, The University of New South Wales, Sydney, New South Wales, Australia.,Department of Renal Medicine, Concord Repatriation General Hospital, Sydney, New South Wales, Australia
| | - Martin P Gallagher
- The George Institute for Global Health, Faculty of Medicine, The University of New South Wales, Sydney, New South Wales, Australia.,Concord Clinical School, Sydney Medical School, Faculty of Health and Medicine, University of Sydney, Sydney, New South Wales, Australia
| | - Vlado Perkovic
- The George Institute for Global Health, Faculty of Medicine, The University of New South Wales, Sydney, New South Wales, Australia
| | - Min Jun
- The George Institute for Global Health, Faculty of Medicine, The University of New South Wales, Sydney, New South Wales, Australia
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26
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Gallacher PJ, Farrah TE, Dominiczak AF, Touyz RM, Adamczak M, Barigou M, Zoghby Z, Hiremath S, Dhaun N. Resistant Hypertension in a Dialysis Patient. Hypertension 2020; 76:278-287. [PMID: 32594796 DOI: 10.1161/hypertensionaha.120.15022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Peter J Gallacher
- From the Department of Renal Medicine, Royal Infirmary of Edinburgh (P.J.G., T.E.F., N.D.).,University/British Heart Foundation Centre of Research Excellence, Centre of Cardiovascular Science, Queen's Medical Research Institute, University of Edinburgh (P.J.G., T.E.F., N.D.)
| | - Tariq E Farrah
- From the Department of Renal Medicine, Royal Infirmary of Edinburgh (P.J.G., T.E.F., N.D.).,University/British Heart Foundation Centre of Research Excellence, Centre of Cardiovascular Science, Queen's Medical Research Institute, University of Edinburgh (P.J.G., T.E.F., N.D.)
| | - Anna F Dominiczak
- Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences (A.F.D.), University of Glasgow, United Kingdom
| | - Rhian M Touyz
- Institute of Cardiovascular and Medical Sciences, BHF Glasgow Cardiovascular Research Centre (R.M.T.), University of Glasgow, United Kingdom
| | - Marcin Adamczak
- Department of Nephrology, Transplantation and Internal Medicine, Medical University of Silesia, Katowice, Poland (M.A.)
| | - Mohammed Barigou
- Endocrinology Diabetes and Metabolism Division, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland (M.B.)
| | - Ziad Zoghby
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic College of Medicine, Rochester, MN (Z.Z.)
| | - Swapnil Hiremath
- Division of Nephrology, Department of Medicine, University of Ottawa, Canada (S.H.)
| | - Neeraj Dhaun
- From the Department of Renal Medicine, Royal Infirmary of Edinburgh (P.J.G., T.E.F., N.D.).,University/British Heart Foundation Centre of Research Excellence, Centre of Cardiovascular Science, Queen's Medical Research Institute, University of Edinburgh (P.J.G., T.E.F., N.D.)
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27
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Abstract
Patients with chronic kidney disease (CKD) are at increased risk for kidney failure, cardiovascular disease (CVD), and death. In fact, the likelihood of dying from CVD is markedly higher than that for reaching end-stage renal disease. Evidence-based management of comorbidities such as CVD remains challenging in patients with advanced CKD, as they were usually excluded from randomized controlled trials. This review focuses on the epidemiology, risk factors, and clinical manifestations of CVD in patients with advanced CKD. Specific topics of interest include diagnostic and therapeutic challenges of heart failure, coronary artery disease, and atrial fibrillation.
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Affiliation(s)
- Turgay Saritas
- Nephrology and Clinical Immunology, University Hospital RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Germany.
| | - Jürgen Floege
- Nephrology and Clinical Immunology, University Hospital RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Germany
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28
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Flythe JE, Chang TI, Gallagher MP, Lindley E, Madero M, Sarafidis PA, Unruh ML, Wang AYM, Weiner DE, Cheung M, Jadoul M, Winkelmayer WC, Polkinghorne KR. Blood pressure and volume management in dialysis: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference. Kidney Int 2020; 97:861-876. [PMID: 32278617 PMCID: PMC7215236 DOI: 10.1016/j.kint.2020.01.046] [Citation(s) in RCA: 106] [Impact Index Per Article: 26.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 12/05/2019] [Accepted: 01/08/2020] [Indexed: 02/07/2023]
Abstract
Blood pressure (BP) and volume control are critical components of dialysis care and have substantial impacts on patient symptoms, quality of life, and cardiovascular complications. Yet, developing consensus best practices for BP and volume control have been challenging, given the absence of objective measures of extracellular volume status and the lack of high-quality evidence for many therapeutic interventions. In February of 2019, Kidney Disease: Improving Global Outcomes (KDIGO) held a Controversies Conference titled Blood Pressure and Volume Management in Dialysis to assess the current state of knowledge related to BP and volume management and identify opportunities to improve clinical and patient-reported outcomes among individuals receiving maintenance dialysis. Four major topics were addressed: BP measurement, BP targets, and pharmacologic management of suboptimal BP; dialysis prescriptions as they relate to BP and volume; extracellular volume assessment and management with a focus on technology-based solutions; and volume-related patient symptoms and experiences. The overarching theme resulting from presentations and discussions was that managing BP and volume in dialysis involves weighing multiple clinical factors and risk considerations as well as patient lifestyle and preferences, all within a narrow therapeutic window for avoiding acute or chronic volume-related complications. Striking this challenging balance requires individualizing the dialysis prescription by incorporating comorbid health conditions, treatment hemodynamic patterns, clinical judgment, and patient preferences into decision-making, all within local resource constraints.
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Affiliation(s)
- Jennifer E Flythe
- University of North Carolina Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, UNC School of Medicine, Chapel Hill, North Carolina, USA; Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, North Carolina, USA.
| | - Tara I Chang
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, California, USA
| | - Martin P Gallagher
- George Institute for Global Health, Renal and Metabolic Division, Camperdown, Australia; Concord Repatriation General Hospital, Department of Renal Medicine, Sydney, Australia
| | - Elizabeth Lindley
- Department of Renal Medicine, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Magdalena Madero
- Department of Medicine, Division of Nephrology, National Institute of Cardiology "Ignacio Chávez", Mexico City, Mexico
| | - Pantelis A Sarafidis
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Mark L Unruh
- Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
| | - Angela Yee-Moon Wang
- Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong, China
| | - Daniel E Weiner
- William B. Schwartz Division of Nephrology, Tufts Medical Center, Boston, Massachusetts, USA
| | | | - Michel Jadoul
- Department of Nephrology, Cliniques universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium
| | - Wolfgang C Winkelmayer
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Kevan R Polkinghorne
- Department of Nephrology, Monash Health, Clayton, Melbourne, Australia; Department of Medicine, Monash University, Clayton, Melbourne, Australia; Department of Epidemiology and Preventive Medicine, Monash University, Prahan, Melbourne, Australia.
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29
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Maruyama T, Takashima H, Abe M. Blood pressure targets and pharmacotherapy for hypertensive patients on hemodialysis. Expert Opin Pharmacother 2020; 21:1219-1240. [PMID: 32281890 DOI: 10.1080/14656566.2020.1746272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Hypertension is highly prevalent in patients with end-stage kidney disease on hemodialysis and is often not well controlled. Blood pressure (BP) levels before and after hemodialysis have a U-shaped relationship with cardiovascular and all-cause mortality. Although antihypertensive drugs are recommended for patients in whom BP cannot be controlled appropriately by non-pharmacological interventions, large-scale randomized controlled clinical trials are lacking. AREAS COVERED The authors review the pharmacotherapy used in hypertensive patients on dialysis, primarily focusing on reports published since 2000. An electronic search of MEDLINE was conducted using relevant key search terms, including 'hypertension', 'pharmacotherapy', 'dialysis', 'kidney disease', and 'antihypertensive drug'. Systematic and narrative reviews and original investigations were retrieved in our research. EXPERT OPINION When a drug is administered to patients on dialysis, the comorbidities and characteristics of each drug, including its dialyzability, should be considered. Pharmacological lowering of BP in hypertensive patients on hemodialysis is associated with improvements in mortality. β-blockers should be considered first-line agents and calcium channel blockers as second-line therapy. Renin-angiotensin-aldosterone system inhibitors have not shown superiority to other antihypertensive drugs for patients on hemodialysis.
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Affiliation(s)
- Takashi Maruyama
- Division of Nephrology, Hypertension and Endocrinology, Department of Internal Medicine, Nihon University School of Medicine , Tokyo, Japan
| | - Hiroyuki Takashima
- Division of Nephrology, Hypertension and Endocrinology, Department of Internal Medicine, Nihon University School of Medicine , Tokyo, Japan
| | - Masanori Abe
- Division of Nephrology, Hypertension and Endocrinology, Department of Internal Medicine, Nihon University School of Medicine , Tokyo, Japan
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30
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Abstract
There is a close physiological relationship between the kidneys and the heart. Cardiovascular diseases are the most prevalent cause of death in patients with chronic kidney disease (CKD), whereas CKD may directly accelerate the progression of cardiovascular diseases and is considered to be a cardiovascular risk factor. In patients with mild CKD, i.e. an estimated glomerular filtration rate (eGFR) >60 ml/min/1.73 m2, treatment of coronary artery disease and chronic heart failure is not essentially different from patients with preserved renal function; however, as most pivotal trials have systematically excluded patients with advanced renal failure, many treatment recommendations in this patient group are based on observational studies, post hoc subgroup analyses and meta-analyses or pathophysiological considerations, which are not supported by controlled studies. Therefore, prospective randomized studies on the management of heart failure and coronary artery disease are needed, which should specifically focus on the growing number of patients with advanced renal functional impairment.
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31
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Lee MS, Zhou H, Shaw SF, Shi J, Reynolds K, Kovesdy CP, Kalantar-Zadeh K, Neyer JR, Jacobsen SJ, Sim JJ. Beta-blocker practice patterns in chronic kidney disease patients with atrial fibrillation transitioning to hemodialysis. Hemodial Int 2019; 23:506-509. [PMID: 31580517 DOI: 10.1111/hdi.12783] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 08/14/2019] [Accepted: 08/24/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Ming-Sum Lee
- Division of Cardiology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California, USA
| | - Hui Zhou
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Sally F Shaw
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Jiaxiao Shi
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Kristi Reynolds
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Csaba P Kovesdy
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Kamyar Kalantar-Zadeh
- Division of Nephrology and Hypertension, University of California Irvine Medical Center, Irvine, California, USA
| | - Jonathon R Neyer
- Division of Cardiology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California, USA
| | - Steven J Jacobsen
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - John J Sim
- Division of Nephrology and Hypertension, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California, USA
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32
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Atrial fibrillation and chronic kidney disease conundrum: an update. J Nephrol 2019; 32:909-917. [DOI: 10.1007/s40620-019-00630-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2019] [Accepted: 07/10/2019] [Indexed: 12/15/2022]
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33
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Antukh DE, Shchekochikhin DY, Nesterov AP, Gilarov MY. Diagnosis and treatment of myocardial infarction in patient with end - stage renal disease on chronic hemodialysis. TERAPEVT ARKH 2019; 91:137-144. [DOI: 10.26442/00403660.2019.06.000203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Indexed: 11/22/2022]
Abstract
This review represents different aspects of myocardial infarction in patient with end - stage renal disease on chronic hemodialysis. We discuss difficulties in diagnosis, optimal method of coronary revascularization, timing of hemodialysis session, medical therapy, as well as epidemiology and prognosis. There are no unambiguous answers to these problems because patients with end - stage renal disease were excluded from most of the studies.
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34
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House AA, Wanner C, Sarnak MJ, Piña IL, McIntyre CW, Komenda P, Kasiske BL, Deswal A, deFilippi CR, Cleland JGF, Anker SD, Herzog CA, Cheung M, Wheeler DC, Winkelmayer WC, McCullough PA. Heart failure in chronic kidney disease: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference. Kidney Int 2019; 95:1304-1317. [PMID: 31053387 DOI: 10.1016/j.kint.2019.02.022] [Citation(s) in RCA: 202] [Impact Index Per Article: 40.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 02/13/2019] [Accepted: 02/21/2019] [Indexed: 12/24/2022]
Abstract
The incidence and prevalence of heart failure (HF) and chronic kidney disease (CKD) are increasing, and as such a better understanding of the interface between both conditions is imperative for developing optimal strategies for their detection, prevention, diagnosis, and management. To this end, Kidney Disease: Improving Global Outcomes (KDIGO) convened an international, multidisciplinary Controversies Conference titled Heart Failure in CKD. Breakout group discussions included (i) HF with preserved ejection fraction (HFpEF) and nondialysis CKD, (ii) HF with reduced ejection fraction (HFrEF) and nondialysis CKD, (iii) HFpEF and dialysis-dependent CKD, (iv) HFrEF and dialysis-dependent CKD, and (v) HF in kidney transplant patients. The questions that formed the basis of discussions are available on the KDIGO website http://kdigo.org/conferences/heart-failure-in-ckd/, and the deliberations from the conference are summarized here.
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Affiliation(s)
- Andrew A House
- Division of Nephrology, Department of Medicine, Western University and London Health Sciences Centre, London, Ontario, Canada.
| | - Christoph Wanner
- Department of Medicine, Division of Nephrology, University Hospital of Würzburg, Würzburg, Germany
| | - Mark J Sarnak
- Department of Medicine, Division of Nephrology, Tufts Medical Center, Boston, Massachusetts, USA
| | - Ileana L Piña
- Division of Cardiology, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York, USA
| | - Christopher W McIntyre
- Division of Nephrology, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada
| | - Paul Komenda
- Department of Internal Medicine, Section of Nephrology, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada; Department of Medicine, Seven Oaks General Hospital, University of Manitoba, Winnipeg, Manitoba, Canada; Department of Community Health Sciences, Seven Oaks General Hospital, University of Manitoba, Winnipeg, Manitoba, Canada
| | | | - Anita Deswal
- Section of Cardiology, Michael E. DeBakey Veteran Affairs Medical Center, Houston, Texas, USA; Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | | | - John G F Cleland
- Robertson Centre for Biostatistics and Clinical Trials, University of Glasgow, Glasgow, UK; National Heart and Lung Institute, Imperial College, London, UK
| | - Stefan D Anker
- Division of Cardiology and Metabolism, Department of Cardiology (CVK), Charité - Universitätsmedizin Berlin, Berlin, Germany; Berlin-Brandenburg Center for Regenerative Therapies (BCRT), Charité - Universitätsmedizin Berlin, Berlin, Germany; Deutsches Zentrum für Herz-Kreislauf-Forschung (DZHK, German Centre for Cardiovascular Research), Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Charles A Herzog
- Division of Cardiology, Department of Medicine, Hennepin County Medical Center and University of Minnesota, Minneapolis, Minnesota, USA; Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, Minnesota, USA
| | | | | | - Wolfgang C Winkelmayer
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Peter A McCullough
- Department of Internal Medicine, Division of Cardiology, Baylor University Medical Center, Dallas, Texas, USA; Department of Internal Medicine, Division of Cardiology, Baylor Heart and Vascular Institute, Dallas, Texas, USA.
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35
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Weinhandl ED. Piecing Together the Risk of Sudden Cardiac Death on Dialysis. J Am Soc Nephrol 2019; 30:521-523. [DOI: 10.1681/asn.2019020185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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36
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Wang KM, Sirich TL, Chang TI. Timing of blood pressure medications and intradialytic hypotension. Semin Dial 2019; 32:201-204. [PMID: 30836447 DOI: 10.1111/sdi.12777] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Intradialytic hypotension (IDH) is a prevalent yet serious complication of hemodialysis, associated with decreased quality of life, inadequate dialysis, vascular access thrombosis, global hypoperfusion, and increased cardiovascular and all-cause mortality. Current guidelines recommend antihypertensive medications be given at night and held the morning of dialysis for affected patients. Despite little evidence to support this recommendation, more than half of patients on dialysis may employ some form of this method. In this article, we will review the available evidence and clinical considerations regarding timing of blood pressure medications and occurrence of IDH, and conclude that witholding BP medications before hemodialysis should not be a routine practice.
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Affiliation(s)
- Katherine M Wang
- Department of Medicine, Stanford Division of Nephrology, Palo Alto, California
| | - Tammy L Sirich
- Department of Medicine, Stanford Division of Nephrology, Palo Alto, California.,Department of Medicine, VA Palo Alto Healthcare System, Palo Alto, California
| | - Tara I Chang
- Department of Medicine, Stanford Division of Nephrology, Palo Alto, California
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37
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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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38
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Abstract
PURPOSE OF REVIEW Hypertension and antihypertensive drug utilization are remarkably prevalent in ESRD patients. Management of blood pressure elevation in this population is complicated by many factors, including a multidimensional etiology, challenges in obtaining accurate and appropriately timed blood pressure measurements, highly specific drug dosing requirements, and a paucity of outcomes-based evidence to guide management decisions. The purpose of this review is to summarize and apply knowledge from existing clinical trials to enhance safe and effective use of antihypertensive agents in dialysis patients. RECENT FINDINGS Two meta-analyses have established the benefit of antihypertensive therapy in ESRD. Data supporting the use of one antihypertensive class over another is less robust; however, beta-blockers have more clearly demonstrated improved cardiovascular outcomes in prospective randomized trials. Interdialytic home blood pressure monitoring has been demonstrated to be better associated with cardiovascular outcomes than clinic pre- or post-dialysis readings and should ideally be considered as a routine part of blood pressure management in this population. As data from small trials provides limited guidance for the management of hypertension in ESRD, more research is needed to guide medication selection and utilization. Specifically, large prospective randomized trails comparing cardiovascular outcomes of various medication classes and differing blood pressure targets are needed.
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Affiliation(s)
- Michelle A Fravel
- Department of Pharmacy Practice and Science, College of Pharmacy, The University of Iowa, 220 PHAR, 115 S. Grand Ave., Iowa City, IA, 52242, USA.
| | - Elizabeth Bald
- Department of Pharmaceutical Care, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Mony Fraer
- Division of Nephrology and Hypertension, Department of Internal Medicine, Carver College of Medicine, The University of Iowa, Iowa City, IA, USA
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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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Bucharles SGE, Wallbach KKS, Moraes TPD, Pecoits-Filho R. Hypertension in patients on dialysis: diagnosis, mechanisms, and management. ACTA ACUST UNITED AC 2018; 41:400-411. [PMID: 30421784 PMCID: PMC6788847 DOI: 10.1590/2175-8239-jbn-2018-0155] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Accepted: 09/05/2018] [Indexed: 12/19/2022]
Abstract
Hypertension (blood pressure > 140/90 mm Hg) is very common in patients undergoing regular dialysis, with a prevalence of 70-80%, and only the minority has adequate blood pressure (BP) control. In contrast to the unclear association of predialytic BP recordings with cardiovascular mortality, prospective studies showed that interdialytic BP, recorded as home BP or by ambulatory blood pressure monitoring in hemodialysis patients, associates more closely with mortality and cardiovascular events. Although BP is measured frequently in the dialysis treatment environment, aspects related to the measurement technique traditionally employed may be unsatisfactory. Several other tools are now available and being used in clinical trials and in clinical practice to evaluate and treat elevated BP in chronic kidney disease (CKD) patients. While we wait for the ongoing review of the CKD Blood Pressure KIDGO guidelines, there is no guideline for the dialysis population addressing this important issue. Thus, the objective of this review is to provide a critical analysis of the information available on the epidemiology, pathogenic mechanisms, and the main pillars involved in the management of blood pressure in stage 5-D CKD, based on current knowledge.
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Affiliation(s)
| | | | | | - Roberto Pecoits-Filho
- Pontifícia Universidade Católica do Paraná, Faculdade de Medicina, Curitiba, PR, Brasil
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Rangaswami J, McCullough PA. Heart Failure in End-Stage Kidney Disease: Pathophysiology, Diagnosis, and Therapeutic Strategies. Semin Nephrol 2018; 38:600-617. [DOI: 10.1016/j.semnephrol.2018.08.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Bansal N, Zelnick LR, Himmelfarb J, Chertow GM. Bioelectrical Impedance Analysis Measures and Clinical Outcomes in CKD. Am J Kidney Dis 2018; 72:662-672. [PMID: 29885923 DOI: 10.1053/j.ajkd.2018.03.030] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Accepted: 03/27/2018] [Indexed: 11/11/2022]
Abstract
RATIONALE & OBJECTIVE Bioelectrical impedance analysis (BIA) provides a noninvasive assessment of body composition. BIA measures of cell integrity (phase angle) and hydration (vector length) have been associated with mortality among patients receiving dialysis. Whether these measures are associated with clinical outcomes in patients with chronic kidney disease (CKD) is unknown. STUDY DESIGN Observational study. SETTINGS & PARTICIPANTS We studied 3,751 participants with CKD in the prospective multicenter Chronic Renal Insufficiency Cohort (CRIC) who had baseline single-frequency BIA performed. PREDICTORS Predictors included phase angle and vector length, which were calculated from measurements of resistance and reactance from BIA. We ranked phase angle and vector length into quartiles and compared the 2 narrower quartiles of phase angle and shorter quartiles of vector length with the 2 upper quartiles. OUTCOMES Mortality, heart failure, atherosclerotic cardiovascular disease, and progression of CKD (30% decline in estimated glomerular filtration rate or end-stage kidney disease). ANALYTIC APPROACH We tested associations of phase angle and vector length with risks for mortality and progression of CKD using Cox proportional hazard models and the association with heart failure and atherosclerotic cardiovascular disease using Fine and Gray models. All models were adjusted for demographics, comorbid conditions, and kidney function. RESULTS Mean phase angle and vector length were 6.6°±1.8° and 470 ± 96 Ω/m, respectively. Relative to phase angle ≥ 6.40o, narrower phase angle (<5.59o) was significantly associated with mortality (HR, 1.31; 95% CI, 1.09-1.58). Relative to vector length ≥ 459 Ω/m, shorter vector length (<401 Ω/m) was significantly associated with heart failure (HR, 1.28; 95% CI, 1.01-1.61). Neither measure was associated with atherosclerotic cardiovascular disease or a composite renal end point. LIMITATIONS Observational study. CONCLUSIONS Adjusted for key confounders, BIA-derived measures of cellular integrity and tissue hydration were significantly associated with death and incident heart failure, respectively.
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Affiliation(s)
- Nisha Bansal
- Division of Nephrology, Kidney Research Institute, University of Washington, Seattle, WA.
| | - Leila R Zelnick
- Division of Nephrology, Kidney Research Institute, University of Washington, Seattle, WA
| | - Jonathan Himmelfarb
- Division of Nephrology, Kidney Research Institute, University of Washington, Seattle, WA
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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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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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Turakhia MP, Blankestijn PJ, Carrero JJ, Clase CM, Deo R, Herzog CA, Kasner SE, Passman RS, Pecoits-Filho R, Reinecke H, Shroff GR, Zareba W, Cheung M, Wheeler DC, Winkelmayer WC, Wanner C. Chronic kidney disease and arrhythmias: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference. Eur Heart J 2018; 39:2314-2325. [PMID: 29522134 PMCID: PMC6012907 DOI: 10.1093/eurheartj/ehy060] [Citation(s) in RCA: 159] [Impact Index Per Article: 26.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Revised: 12/18/2017] [Accepted: 01/27/2018] [Indexed: 12/15/2022] Open
MESH Headings
- Arrhythmias, Cardiac/epidemiology
- Arrhythmias, Cardiac/therapy
- Atrial Fibrillation/complications
- Atrial Fibrillation/drug therapy
- Atrial Fibrillation/epidemiology
- Death, Sudden, Cardiac/prevention & control
- Defibrillators, Implantable
- Humans
- Hyperkalemia/epidemiology
- Hyperkalemia/metabolism
- Hypokalemia/epidemiology
- Hypokalemia/metabolism
- Inflammation
- Kidney Failure, Chronic/epidemiology
- Kidney Failure, Chronic/metabolism
- Kidney Failure, Chronic/therapy
- Oxidative Stress
- Potassium/metabolism
- Renal Dialysis
- Renal Insufficiency, Chronic/epidemiology
- Renal Insufficiency, Chronic/metabolism
- Renal Insufficiency, Chronic/therapy
- Risk Factors
- Stroke/etiology
- Stroke/prevention & control
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Affiliation(s)
- Mintu P Turakhia
- Stanford University School of Medicine, Veterans Affairs Palo Alto Health Care System, Miranda Ave, Palo Alto, CA, USA
| | - Peter J Blankestijn
- Department of Nephrology, room F03.220, University Medical Center, Utrecht, The Netherlands
| | - Juan-Jesus Carrero
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Nobels väg 12A, Stockholm, Sweden
| | - Catherine M Clase
- Department of Medicine and Department of Health Research Methods, Evidence, and Impact, McMaster University, St. Joseph’s Healthcare, Marian Wing, 3rd Floor, M333, 50 Charlton Ave. E, Hamilton, Ontario, Canada
| | - Rajat Deo
- Section of Electrophysiology, Division of Cardiovascular Medicine, Perelman School of Medicine at the University of Pennsylvania, 3400 Spruce Street, 9 Founders Cardiology, Philadelphia, PA, USA
| | - Charles A Herzog
- Division of Cardiology, Department of Medicine, Hennepin County Medical Center and University of Minnesota, Minneapolis, Minnesota and Chronic Disease Research Group, Minneapolis Medical Research Foundation, 914 S. 8th Street, S4.100, Minneapolis, MN, USA
| | - Scott E Kasner
- Department of Neurology, 3W Gates Bldg. Hospital of the University of Pennsylvania, 3400 Spruce St., Philadelphia, PA, USA
| | - Rod S Passman
- Northwestern University Feinberg School of Medicine and the Bluhm Cardiovascular Institute, 201 E. Huron St. Chicago, IL, USA
| | - Roberto Pecoits-Filho
- School of Medicine, Pontificia Universidade Catolica do Paraná, Rua Imaculada Conceição Curitiba PR, Brazil
| | - Holger Reinecke
- Department für Kardiologie und Angiologie Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, Gebäude A1, Muenster, Germany
| | - Gautam R Shroff
- Division of Cardiology, Hennepin County Medical Center, 701 Park Avenue, Minneapolis, MN, USA
| | - Wojciech Zareba
- Heart Research Follow-up Program, Cardiology Division, University of Rochester Medical Center, Saunders Research Building, 265 Crittenden Blvd. CU, Rochester, NY, USA
| | | | - David C Wheeler
- Centre for Nephrology, University College London, Rowland Hill Street, London, UK
| | - Wolfgang C Winkelmayer
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, One Baylor Plaza, ABBR R705, MS: 395, Houston, TX, USA
| | - Christoph Wanner
- Division of Nephrology, Department of Medicine, University Hospital of Würzburg, Oberduerrbacherstr. 6 Würzburg, Germany
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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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Tieu A, Velenosi TJ, Kucey AS, Weir MA, Urquhart BL. β-Blocker Dialyzability in Maintenance Hemodialysis Patients: A Randomized Clinical Trial. Clin J Am Soc Nephrol 2018; 13:604-611. [PMID: 29519953 PMCID: PMC5969458 DOI: 10.2215/cjn.07470717] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2017] [Accepted: 01/05/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND OBJECTIVES There is a paucity of data available to describe drug dialyzability. Of the available information, most was obtained before implementation of modern hemodialysis membranes. Our study characterized dialyzability of the most commonly prescribed β-blockers in patients undergoing high-flux hemodialysis. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Patients on hemodialysis (n=8) were recruited to an open label, pharmacokinetic, four-way crossover trial. Single doses of atenolol, metoprolol, bisoprolol, and carvedilol were administered on separate days in random order to each patient. Plasma and dialysate drug concentrations were measured, and dialyzability was determined by the recovery clearance and arterial venous difference methods. RESULTS Using the recovery clearance method, the dialytic clearance values for atenolol, metoprolol, bisoprolol, and carvedilol were 72, 87, 44, and 0.2 ml/min, respectively (P<0.001). Applying the arterial venous difference method, the dialytic clearance values of atenolol, metoprolol, bisoprolol, and carvedilol were 167, 114, 96, and 24 ml/min, respectively (P<0.001). CONCLUSIONS Atenolol and metoprolol are extensively cleared by hemodialysis compared with the negligible dialytic clearance of carvedilol. Contrary to estimates of dialyzability on the basis of previous literature, our data indicate that bisoprolol is also dialyzable. This finding highlights the importance of conducting dialyzability studies to definitively characterize drug dialytic clearance.
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Affiliation(s)
- Alvin Tieu
- Departments of Physiology and Pharmacology and
| | | | | | - Matthew A. Weir
- Division of Nephrology, and
- Epidemiology and Biostatistics, Department of Medicine, Schulich School of Medicine and Dentistry, The University of Western Ontario, London, Ontario, Canada; and
| | - Bradley L. Urquhart
- Departments of Physiology and Pharmacology and
- Epidemiology and Biostatistics, Department of Medicine, Schulich School of Medicine and Dentistry, The University of Western Ontario, London, Ontario, Canada; and
- Lawson Health Research Institute, London, Ontario, Canada
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48
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Cutshall BT, Duhart BT, Saikumar J, Samarin M, Hutchison L, Hudson JQ. Assessing Guideline-Directed Medication Therapy for Heart Failure in End-Stage Renal Disease. Am J Med Sci 2018; 355:247-251. [PMID: 29549927 DOI: 10.1016/j.amjms.2017.11.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Accepted: 11/17/2017] [Indexed: 01/13/2023]
Abstract
BACKGROUND Treatment of heart failure with reduced ejection fraction (HFrEF) requires guideline-directed medication therapy (GDMT) consisting of either an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker in combination with an indicated beta-blocker. There is concern that end-stage renal disease (ESRD) patients are not being prescribed GDMT. The study aim was to determine whether outcomes differ for patients with HFrEF and ESRD receiving GDMT compared to those not receiving GDMT. MATERIALS AND METHODS Adult patients with ESRD and HFrEF admitted to a tertiary teaching hospital over a 2-year period were included. Patients were categorized into GDMT or non-GDMT groups based on their home medications. The length of stay (LOS), mortality, and 30-day hospital readmissions were compared between groups. The incidence of hyperkalemia, hypotension and bradycardia were also evaluated. RESULTS A total of 109 patients were included: 88% African-American, 61% males, median age 63 (28-93) years with 25 in the GDMT group and 84 in the non-GDMT group. The LOS did not differ between the GDMT (5 days; 3-14) compared to the non-GDMT group (7 days; 3-28), P = 0.14. Thirty-day hospital readmission and in-hospital mortality were also similar. Hypotension occurred less frequently in the GDMT group compared to the non-GDMT group, 4% versus 27% (P = 0.01). CONCLUSIONS Although there were no differences in the primary outcomes, the shorter LOS in the GDMT group may be clinically significant. The fact that most patients with ESRD and HFrEF were not receiving GDMT is a finding that requires further evaluation.
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Affiliation(s)
- B Tate Cutshall
- The University of Alabama at Birmingham Medical Center, Birmingham, AL
| | - Benjamin T Duhart
- Department of Clinical Pharmacy and Translational Science, The University of Tennessee College of Pharmacy, Memphis, TN
| | - Jagannath Saikumar
- Department of Medicine (Nephrology), The University of Tennessee, Memphis, TN
| | - Michael Samarin
- Department of Pharmacy, Methodist University Hospital, Memphis, TN
| | - Lydia Hutchison
- Department of Pharmacy, Methodist University Hospital, Memphis, TN
| | - Joanna Q Hudson
- Department of Clinical Pharmacy and Translational Science, The University of Tennessee College of Pharmacy, Memphis, TN; Department of Medicine (Nephrology), The University of Tennessee, Memphis, TN.
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Inampudi C, Alvarez P, Asleh R, Briasoulis A. Therapeutic Approach to Patients with Heart Failure with Reduced Ejection Fraction and End-stage Renal Disease. Curr Cardiol Rev 2018; 14:60-66. [PMID: 29366423 PMCID: PMC5872264 DOI: 10.2174/1573403x14666180123164916] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2017] [Revised: 01/11/2018] [Accepted: 01/15/2018] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Several risk factors including Ischemic heart disease, uncontrolled hypertension, high output Heart Failure (HF) from shunting through vascular hemodialysis access, and anemia, contribute to development of HF in patients with End-Stage Renal Disease (ESRD). Guidelinedirected medical and device therapy for Heart Failure with Reduced Ejection Fraction (HFrEF) has not been extensively studied and may have limited safety and efficacy in patients with ESRD. RESULTS Maintenance of interdialytic and intradialytic euvolemia is a key component of HF management in these patients but often difficult to achieve. Beta-blockers, especially carvedilol which is poorly dialyzed is associated with cardiovascular benefit in this population. Despite paucity of data, Angiotensin-converting Enzyme Inhibitors (ACEI) or Angiotensin II Receptor Blockers (ARBs) when appropriately adjusted by dose and with close monitoring of serum potassium can also be administered to these patients who tolerate beta-blockers. Mineralocorticoid receptors in patients with HFrEF and ESRD have been shown to reduce mortality in a large randomized controlled trial without any significantly increased risk of hyperkalemia. Implantable Cardiac-defibrillators (ICDs) should be considered for primary prevention of sudden cardiac death in patients with HFrEF and ESRD who meet the implant indications. Furthermore in anemic iron-deficient patients, intravenous iron infusion may improve functional status. Finally, mechanical circulatory support with leftventricular assist devices may be related to increased mortality risk and the presence of ESRD poses a relative contraindication to further evaluation of these devices.
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Affiliation(s)
- Chakradhari Inampudi
- Division of Cardiovascular Diseases, Section of Heart Failure and Transplant, University of Iowa Hospitals and Clinics, Iowa City, IA, United States
| | - Paulino Alvarez
- Division of Cardiovascular Diseases, Section of Heart Failure and Transplant, University of Iowa Hospitals and Clinics, Iowa City, IA, United States
| | - Rabea Asleh
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester MN, United States
| | - Alexandros Briasoulis
- Division of Cardiovascular Diseases, Section of Heart Failure and Transplant, University of Iowa Hospitals and Clinics, Iowa City, IA, United States
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50
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Battistella M, Jandoc R, Ng JY, McArthur E, Garg AX. A Province-wide, Cross-sectional Study of Demographics and Medication Use of Patients in Hemodialysis Units Across Ontario. Can J Kidney Health Dis 2018; 5:2054358118760832. [PMID: 29568537 PMCID: PMC5858734 DOI: 10.1177/2054358118760832] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Accepted: 12/12/2017] [Indexed: 01/05/2023] Open
Abstract
Background: Hemodialysis patients are at an increased risk of polypharmacy as they have the highest
pill burden of all chronically ill patient populations, with an estimated average of 12
medications per day. Objectives: The aim of this study was to evaluate prescribing patterns of outpatient medications in
patients receiving in-center hemodialysis. This was done to identify potential candidate
medications for future quality improvement initiations to optimize prescribing. Design: We conducted a descriptive retrospective cross-sectional study in the province of
Ontario, Canada, using several linked health care databases housed at the Institute for
Clinical Evaluative Sciences (ICES). Setting: We considered outpatient medications dispensed to patients eligible for the Ontario
Drug Benefit program. Patients: Patients were receiving chronic in-center hemodialysis at one of the 69 facilities in
the province of Ontario, Canada as of October 1, 2013. Measurements: We assessed whether any of our 28 study medications of interest were recently dispensed
(within the prior 120 days), the type of prescribing physician, and the associated
medication costs. The 28 included medications of interest (ie, proton pump inhibitors,
benzodiazepines) were selected because they may not have a true indication for dialysis
patients and/or there are safety concerns with their use in this population. Results are
presented as median (25th, 75th percentile). Methods: We conducted this study at ICES according to a prespecified protocol approved by the
Research Ethics Board at Sunnybrook Health Sciences Centre (Toronto, Ontario). Results: A total of 3094 patients on chronic in-center hemodialysis received a study drug of
interest (age: 76.5 years [SD: 7.3]), 44% women). Patients were dispensed 11 (8, 14)
unique medication products with more than two-thirds of patients dispensed 9 or more
different medications. The median number of annual health care visits was 7 (3-15) with
more than half the cohort receiving prescriptions from 3 or more specialists. The 10
most commonly dispensed study medications cost more than 3 million dollars in direct
costs in 1 year. Limitations: Our study was also subjected to some limitations of health care databases. Conclusions: Polypharmacy is frequent in in-center hemodialysis patients. To decrease polypharmacy
and its associated negative outcomes, health care providers need to implement tools to
optimize medication use and deprescribe medications that lack evidence for efficacy and
safety in hemodialysis patients. Therefore, strategies to improve prescribing and
discontinue ineffective medications warrant testing for better patient outcomes and
reduced health care costs.
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Affiliation(s)
- Marisa Battistella
- Department of Pharmacy, University Health Network, Toronto, Ontario, Canada.,Faculty of Pharmacy, University of Toronto, Ontario, Canada
| | - Racquel Jandoc
- Institute for Clinical Evaluative Sciences, London, Ontario, Canada
| | - Jeremy Y Ng
- Department of Pharmacy, University Health Network, Toronto, Ontario, Canada.,Faculty of Pharmacy, University of Toronto, Ontario, Canada
| | - Eric McArthur
- Institute for Clinical Evaluative Sciences, London, Ontario, Canada
| | - Amit X Garg
- Institute for Clinical Evaluative Sciences, London, Ontario, Canada.,Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada.,Department of Medicine, Western University, London, Ontario, Canada
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