Antihypertensive medications and risk of death and hospitalizations in US hemodialysis patients: Evidence from a cohort study to inform hypertension treatment practices.
Antihypertensive medications are commonly prescribed to hemodialysis patients but the optimal regimens to prevent morbidity and mortality are unknown. The goal of our study was to compare the association of routinely prescribed antihypertensive regimens with outcomes in US hemodialysis patients.We used 2 datasets for our analysis. Our primary cohort (US Renal Data System [USRDS]) included adult patients initiating in-center hemodialysis from July 1, 2006 to June 30, 2008 (n = 33,005) with follow-up through December 31, 2009. Our secondary cohort included adult patients from Dialysis Clinic, Inc. (DCI), a national not-for-profit dialysis provider, initiating in-center hemodialysis from January 1, 2003 to June 30, 2008 (n = 11,291) with follow-up through December 31, 2008. We linked the USRDS cohort with Medicare part D prescriptions-fill data and the DCI cohort with USRDS data. Unique aspect of USRDS cohort was pharmacy prescription-fill data and for DCI cohort was detailed clinical data, including blood pressure, weight, and ultrafiltration. We classified prescribed antihypertensives into the following mutually exclusive regimens: β-blockers, renin-angiotensin system blocking drugs-containing regimens without a β-blocker (RAS), β-blocker + RAS, and others. We used marginal structural models accounting for time-updated comorbidities to quantify each regimen's association with mortality (both cohorts) and cardiovascular hospitalization (DCI-Medicare Subcohort).In the USRDS and DCI cohorts there were 9655 (29%) and 3200 (28%) deaths, respectively. In both cohorts, RAS compared to β-blockers regimens were associated with lower risk of death; (hazard ratio [HR]) (95% confidence interval [CI]) for all-cause mortality, (0.90 [0.82-0.97] in USRDS and 0.87 [0.76-0.98] in DCI) and cardiovascular mortality (0.84 [0.75-0.95] in USRDS and 0.88 [0.71-1.07] in DCI). There was no association between antihypertensive regimens and the risk of cardiovascular hospitalizations.In hemodialysis patients undergoing routine care, renin-angiotensin system blocking drugs-containing regimens were associated with a lower risk of death compared with β-blockers-containing regimens but there was no association with cardiovascular hospitalizations. Pragmatic clinical trials are needed to specifically examine the effectiveness of these commonly used antihypertensive regimens in dialysis patients.
Division of Nephrology, Johns Hopkins University School of Medicine Welch Center for Prevention, Epidemiology, and Clinical Research Department of Health Policy and Management Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD College of Pharmacy, University of Minnesota Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, MN Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD Department of Internal Medicine, Hennepin County Medical Center, University of Minnesota Cardiovascular Special Studies Center, United States Renal Data System, Minneapolis, MN Department of Nephrology, Duke University School of Medicine, Durham, NC Department of Medicine, Division of Nephrology, Seven Oaks General Hospital, University of Manitoba, Winnipeg, Manitoba, Canada Division of Nephrology, Tufts University School of Medicine, Boston, MA Division of Nephrology, Department of Medicine, Academic Medical Center, Amsterdam, The Netherlands Nephrology Center of Maryland, Baltimore, MD Division of Nephrology, University of New Mexico, Albuquerque, New Mexico Department of Health Policy and Management Department of International Health Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD Division of General Internal Medicine, Duke University School of Medicine, Durham, NC, USA.
Tariq
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Shafi
Stephen M
SM
Sozio
Jason
J
Luly
Karen J
KJ
Bandeen-Roche
Wendy L
WL
St Peter
Patti L
PL
Ephraim
Aidan
A
McDermott
Charles A
CA
Herzog
Deidra C
DC
Crews
Julia J
JJ
Scialla
Navdeep
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Tangri
Dana C
DC
Miskulin
Wieneke M
WM
Michels
Bernard G
BG
Jaar
Philip G
PG
Zager
Klemens B
KB
Meyer
Albert W
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Wu
L Ebony
LE
Boulware
D000319:Adrenergic beta-Antagonists / Q000627:therapeutic use; D000368:Aged; D057912:Angiotensin II Type 2 Receptor Blockers / Q000627:therapeutic use; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000627:therapeutic use; D000959:Antihypertensive Agents / Q000008:administration & dosage / Q000627:therapeutic use*; D002318:Cardiovascular Diseases / Q000401:mortality; D015897:Comorbidity; D005260:Female; D006760:Hospitalization / Q000706:statistics & numerical data*; D006801:Humans; D006973:Hypertension / Q000188:drug therapy* / Q000453:epidemiology; D007676:Kidney Failure, Chronic / Q000453:epidemiology / Q000401:mortality* / Q000628:therapy; D008297:Male; D008875:Middle Aged; D006435:Renal Dialysis / Q000401:mortality*
D000319:Adrenergic beta-Antagonists; D057912:Angiotensin II Type 2 Receptor Blockers; D000806:Angiotensin-Converting Enzyme Inhibitors; D000959:Antihypertensive Agents