Cardiovascular events account for nearly half of all deaths among dialysis patients. Although antihypertensive agents have been found to reduce CV events in the general population, their effect in dialysis patients has been uncertain. Now a new meta-analysis in The Lancet shows that treating dialysis patients with antihypertensive agents could reduce all cause mortality by 20%, and cardiovascular events and mortality by 29%.
However, an accompanying comment by Charles Tomson, of Southmead Hospital in Bristol, UK, notes that many nephrologists will remain “reluctant to prescribe antihypertensive drugs” to dialysis patients except for those with high blood pressure throughout “the dialysis cycle becasue of permanent but subclinical volume expansion.”
Here is The Lancet press release:
LOWERING BLOOD PRESSURE PREVENTS CARDIOVASCULAR EVENTS AND DEATHS IN DIALYSIS PATIENTS
Lowering blood pressure protects dialysis patients from major cardiovascular events and death, and treatment with blood-pressure lowering drugs should be routinely considered for patients undergoing dialysis. These are the conclusions of an Article published Online First and in an upcoming edition of The Lancet.
Globally, hundreds of thousands of people receive dialysis for chronic kidney disease. These individuals are at high risk of cardiovascular events and death—every year between 10% and 20% of patients on dialysis die, with nearly half these deaths due to cardiovascular causes. But there are currently no treatments available that have been proven to reduce this risk.
Several previous studies have shown the cardiovascular benefits of lowering blood pressure in the general population and in patients with early kidney disease, but the efficacy and safety of blood-pressure lowering in dialysis patients is not clear. Indeed, the first trials on blood-pressuring lowering in dialysis patients reported conflicting results.
To resolve this uncertainty, Vlado Perkovic from The George Institute for International Health in Australia and international colleagues, systematically reviewed eight randomised controlled trials that assessed the effect of blood-pressure lowering in 1679 adult patients on dialysis, and involved 495 cardiovascular events.
Overall, findings showed that treatment with blood-pressure lowering drugs was associated with a reduced risk of cardiovascular complications, all-cause mortality and cardiovascular deaths compared with controls. Data from seven trials showed that the weighted mean systolic blood pressure was 4.5mm HG lower and diastolic blood pressure 2.3mm Hg lower in actively treated patients than in controls.
The protective effects of treatment with blood–pressure lowering drugs was found to be similar regardless of hypertension and other disorders and across a range of drug classes. However, the studies did not provide enough data to measure the effects of blood-pressure lowering for specific drug classes.
In addition, the authors found that blood pressure-lowering was well tolerated, with no evidence of a higher dropout rate in the active treatment groups compared to control groups.
The authors conclude: “If our data are applied to a broad population of patients on dialysis with an annual mortality rate of about 10%, we calculate that blood-pressure lowering treatment could prevent two of the ten deaths expected to occur in every 100 patients per year. This absolute benefit will be greater for individuals at higher absolute risk, and is much greater than that reported for many other interventions in routine use.”
In an accompanying Comment, Charles Tomson from Southmead Hospital in Bristol, UK, welcomes the findings of the study because of the lack of randomised trials in patients with kidney disease, but discusses why he considers that the findings are unlikely to result in an immediate change in practice.
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