title: Antihypertensive Medication Use in Older Patients Transitioning from Chronic Kidney Disease to End-Stage Renal Disease on Dialysis.
abstract: The transition from CKD to ESRD can be particularly unstable, with high rates of death and hospitalizations. Few studies have examined medication use during this critical period. We examined patterns of antihypertensive medication use from the four quarters before and eight quarters after incident ESRD treated with maintenance dialysis.
  
  
  
  We used the US Renal Data System to identify patients aged ≥67 years initiating dialysis for ESRD between January 2008 and December 2010 with Medicare Part D and a low-income subsidy. We ascertained the incidence of AKI and hyperkalemia during each quarter on the basis of having at least 1 payment claim for the condition. We used Poisson regression with robust SEMs to formally test for changes in the trend and level of antihypertensive medication use in a series of intervention analyses.
  
  
  
  The number of antihypertensive drugs used increased as patients neared ESRD, peaking at an average of 3.4 in the quarter immediately preceding dialysis initiation, then declining to 2.2 medications by 2 years later. Angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker use was stable at approximately 40%, even among patients with coronary disease and systolic heart failure, and did not correlate with AKI or hyperkalemia. Dialysis initiation was associated with a 40% (95% confidence interval, 38% to 43%) lower adjusted level of diuretic use, which continued to decline after ESRD. Three- and four-drug combinations that included a diuretic were most common before ESRD, whereas after ESRD, one- and two-drug β-blocker or calcium-channel blocker-based combinations were most common.
  
  
  
  The use of antihypertensive medications, particularly angiotensin-converting enzyme inhibitor/angiotensin II receptor blockers and diuretics, may be suboptimal during the transition from CKD to ESRD, especially in patients with coronary disease or systolic heart failure. Future studies are needed to identify strategies to increase the appropriate use of antihypertensive medications during this critical transition period.
authors.affiliation: Division of Nephrology, Stanford University School of Medicine, Stanford, California; and.
authors.forename: Tara I
authors.initials: TI
authors.lastname: Chang
authors.affiliation: Division of Nephrology, Stanford University School of Medicine, Stanford, California; and.
authors.forename: Yuanchao
authors.initials: Y
authors.lastname: Zheng
authors.affiliation: Division of Nephrology, Stanford University School of Medicine, Stanford, California; and.
authors.forename: Maria E
authors.initials: ME
authors.lastname: Montez-Rath
authors.affiliation: Selzman Institute for Kidney Health, Section of Nephrology, Baylor College of Medicine, Houston, Texas.
authors.forename: Wolfgang C
authors.initials: WC
authors.lastname: Winkelmayer
mesh_terms: D058186:Acute Kidney Injury / Q000453:epidemiology; D000368:Aged; D000369:Aged, 80 and over; D057911:Angiotensin Receptor Antagonists / Q000627:therapeutic use; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000627:therapeutic use; D000959:Antihypertensive Agents / Q000627:therapeutic use*; D015897:Comorbidity; D003327:Coronary Disease / Q000453:epidemiology; D018450:Disease Progression; D004232:Diuretics / Q000627:therapeutic use; D011307:Drug Prescriptions / Q000706:statistics & numerical data*; D004359:Drug Therapy, Combination; D005260:Female; D006333:Heart Failure / Q000453:epidemiology; D006801:Humans; D006947:Hyperkalemia / Q000453:epidemiology; D006973:Hypertension / Q000188:drug therapy*; D007676:Kidney Failure, Chronic / Q000453:epidemiology* / Q000503:physiopathology / Q000628:therapy*; D008297:Male; D006435:Renal Dialysis; D051436:Renal Insufficiency, Chronic / Q000453:epidemiology / Q000503:physiopathology
chemical_list: D057911:Angiotensin Receptor Antagonists; D000806:Angiotensin-Converting Enzyme Inhibitors; D000959:Antihypertensive Agents; D004232:Diuretics
keywords: ACE inhibitors; acute kidney injury; antihypertensive agents; blood pressure; cardiovascular disease; coronary artery disease; hospitalization; humans; hyperkalemia; kidney failure, chronic; renal dialysis