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Medicine (Baltimore). 2017 Feb;96(5):e5924. doi: 10.1097/MD.0000000000005924.

Antihypertensive medications and risk of death and hospitalizations in US hemodialysis patients: Evidence from a cohort study to inform hypertension treatment practices.

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aDivision of Nephrology, Johns Hopkins University School of Medicine bWelch Center for Prevention, Epidemiology, and Clinical Research cDepartment of Health Policy and Management dDepartment of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD eCollege of Pharmacy, University of Minnesota fChronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, MN gDepartment of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD hDepartment of Internal Medicine, Hennepin County Medical Center, University of Minnesota iCardiovascular Special Studies Center, United States Renal Data System, Minneapolis, MN jDepartment of Nephrology, Duke University School of Medicine, Durham, NC kDepartment of Medicine, Division of Nephrology, Seven Oaks General Hospital, University of Manitoba, Winnipeg, Manitoba, Canada lDivision of Nephrology, Tufts University School of Medicine, Boston, MA mDivision of Nephrology, Department of Medicine, Academic Medical Center, Amsterdam, The Netherlands nNephrology Center of Maryland, Baltimore, MD oDivision of Nephrology, University of New Mexico, Albuquerque, New Mexico pDepartment of Health Policy and Management qDepartment of International Health rDepartment of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD sDivision of General Internal Medicine, Duke University School of Medicine, Durham, NC, USA.


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.

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Free PMC Article

Conflict of interest statement

AHRQ Disclosure: Identifiable information, on which this report, presentation, or other form of disclosure is based, is confidential and protected by federal law, Section 903(c) of the Public Health Service Act, 42 USC 299a-1(c). Any identifiable information that is knowingly disclosed is disclosed solely for the purpose for which it has been supplied. No identifiable information about any individual supplying the information or described in it will be knowingly disclosed except with the prior consent of that individual. The authors declare that they have no competing interests. The authors have no conflicts of interest to disclose.

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