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Current Hypertension Reports
Published in: Current Hypertension Reports 5/2010

01-10-2010

Should All Hypertensive Dialysis Patients Receive a Blocker of the Renin-Angiotensin System?

Authors: Arjun D. Sinha, Rajiv Agarwal

Published in: Current Hypertension Reports | Issue 5/2010

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Abstract

Cardiovascular mortality and hypertension remain common in the dialysis population, and two recent meta-analyses have suggested that antihypertensive pharmacotherapy reduces cardiovascular events in dialysis patients. Based on their benefits in other populations, blockers of the renin-angiotensin-aldosterone system (RAAS) are an attractive treatment option. The evidence that RAAS blockers improve surrogate end points is mixed. However, a recent meta-analysis found significant improvement in left ventricular mass with RAAS-blocking drugs in hemodialysis patients. Only a few trials have examined RAAS-blocking drugs and cardiovascular events in dialysis patients, and a recent meta-analysis found no significant benefit in hemodialysis patients. The single trial of peritoneal dialysis patients that reported cardiovascular events found no benefit from RAAS blockers. Fortunately, the risk of hyperkalemia appears low. Based on the available evidence, we cannot categorically recommend that all hypertensive dialysis patients be treated with RAAS blockers. We await the results of adequately powered clinical trials.
Literature
1.
U S Renal Data System: USRDS 2009 Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States. Bethesda, MD: National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases; 2009.
2.
Agarwal R, Nissenson AR, Batlle D, et al.: Prevalence, treatment, and control of hypertension in chronic hemodialysis patients in the United States. Am J Med 2003, 115:291–297.CrossRefPubMed
3.
• Agarwal R, Sinha AD: Cardiovascular protection with antihypertensive drugs in dialysis patients: systematic review and meta-analysis. Hypertension 2009, 53:860–866. This is an up-to-date meta-analysis of the available randomized clinical trials of antihypertensive medications in hemodialysis patients. The authors found antihypertensive therapy to be associated with a significant improvement in cardiovascular events, compared with controls. Hypertensive patients appeared to benefit more than normotensive patients.CrossRefPubMed
4.
• Heerspink HJ, Ninomiya T, Zoungas S, et al.: Effect of lowering blood pressure on cardiovascular events and mortality in patients on dialysis: a systematic review and meta-analysis of randomised controlled trials. Lancet 2009, 373:1009–1015. This is an up-to-date meta-analysis of the available randomized clinical trials of antihypertensive medications in hemodialysis and PD patients. The authors found antihypertensive therapy to be associated with a significant improvement in cardiovascular events and in all-cause mortality compared with controls.CrossRefPubMed
5.
Agarwal R, Alborzi P, Satyan S, Light RP: Dry-weight reduction in hypertensive hemodialysis patients (DRIP): a randomized, controlled trial. Hypertension 2009, 53:500–507.CrossRefPubMed
6.
Lazarus JM, Hampers C, Merrill JP: Hypertension in chronic renal failure. Treatment with hemodialysis and nephrectomy. Arch Intern Med 1974, 133:1059–1066.CrossRefPubMed
7.
Campese VM, Mitra N, Sandee D: Hypertension in renal parenchymal disease: Why is it so resistant to treatment? Kidney Int 2006, 69:967–973.CrossRefPubMed
8.
Agarwal R, Lewis R, Davis JL, Becker B: Lisinopril therapy for hemodialysis hypertension: hemodynamic and endocrine responses. Am J Kidney Dis 2001, 38:1245–1250.CrossRefPubMed
9.
Zheng S, Nath V, Coyne DW: ACE inhibitor-based, directly observed therapy for hypertension in hemodialysis patients. Am J Nephrol 2007, 27:522–529.CrossRefPubMed
10.
Saracho R, Martin-Malo A, Martinez I, et al.: Evaluation of the Losartan in Hemodialysis (ELHE) Study. Kidney Int 1998, 68:S125–S129.CrossRef
11.
Gross E, Rothstein M, Dombek S, Juknis HI: Effect of spironolactone on blood pressure and the renin-angiotensin-aldosterone system in oligo-anuric hemodialysis patients. Am J Kidney Dis 2005, 46:94–101.CrossRefPubMed
12.
Krediet RT: How to preserve residual renal function in patients with chronic kidney disease and on dialysis? Nephrol Dial Transplant 2006, 21(Suppl 2):ii42–ii46.CrossRefPubMed
13.
Jafar TH, Stark PC, Schmid CH, et al.: Progression of chronic kidney disease: the role of blood pressure control, proteinuria, and angiotensin-converting enzyme inhibition: a patient-level meta-analysis. Ann Intern Med 2003, 139:244–252.PubMed
14.
• Akbari A, Knoll G, Ferguson D, et al.: Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers in peritoneal dialysis: systematic review and meta-analysis of randomized controlled trials. Perit Dial Int 2009, 29:554–561. This is an up-to-date systematic review and meta-analysis of the very few randomized clinical trials of ACE inhibitor and ARB therapy in PD patients. The pooled estimate from two trials found a significant slowing in loss of residual renal function at 1 year. Only a single study had cardiovascular events to report as an outcome, and there were no differences between the intervention and control groups.PubMed
15.
Li PK, Chow KM, Wong TY, et al.: Effects of an angiotensin-converting enzyme inhibitor on residual renal function in patients receiving peritoneal dialysis. A randomized, controlled study. Ann Intern Med 2003, 139:105–112.PubMed
16.
Suzuki H, Kanno Y, Sugahara S, et al.: Effects of an angiotensin II receptor blocker, valsartan, on residual renal function in patients on CAPD. Am J Kidney Dis 2004, 43:1056–1064.CrossRefPubMed
17.
Blacher J, Guerin AP, Pannier B, et al.: Impact of aortic stiffness on survival in end-stage renal disease. Circulation 1999, 99:2434–2439.PubMed
18.
Huang WH, Hsu CW, Chen YC, et al.: Angiotensin II receptor antagonists supplementation is associated with arterial stiffness: insight from a retrospective study in 116 peritoneal dialysis patients. Ren Fail 2007, 29:843–848.CrossRefPubMed
19.
Ichihara A, Hayashi M, Kaneshiro Y, et al.: Low doses of losartan and trandolapril improve arterial stiffness in hemodialysis patients. Am J Kidney Dis 2005, 45:866–874.CrossRefPubMed
20.
Mitsuhashi H, Tamura K, Yamauchi J, et al.: Effect of losartan on ambulatory short-term blood pressure variability and cardiovascular remodeling in hypertensive patients on hemodialysis. Atherosclerosis 2009, 207:186–190.CrossRefPubMed
21.
Shigenaga A, Tamura K, Dejima T, et al.: Effects of angiotensin II type 1 receptor blocker on blood pressure variability and cardiovascular remodeling in hypertensive patients on chronic peritoneal dialysis. Nephron Clin Pract 2009, 112:c31–c40.CrossRefPubMed
22.
Edwards NC, Steeds RP, Stewart PM, et al.: Effect of spironolactone on left ventricular mass and aortic stiffness in early-stage chronic kidney disease: a randomized controlled trial. J Am Coll Cardiol 2009, 54:505–512.CrossRefPubMed
23.
Suzuki H, Nakamoto H, Okada H, et al.: A selective angiotensin receptor antagonist, valsartan, produced regression of left ventricular hypertrophy associated with a reduction of arterial stiffness. Adv Perit Dial 2003, 19:59–66.PubMed
24.
Foley RN, Parfrey PS, Harnett JD, et al.: Clinical and echocardiographic disease in patients starting end-stage renal disease therapy. Kidney Int 1995, 47:186–192.CrossRefPubMed
25.
Silberberg JS, Barre PE, Prichard SS, Sniderman AD: Impact of left ventricular hypertrophy on survival in end-stage renal disease. Kidney Int 1989, 36:286–290.CrossRefPubMed
26.
Cannella G, Paoletti E, Delfino R, et al.: Prolonged therapy with ACE inhibitors induces a regression of left ventricular hypertrophy of dialyzed uremic patients independently from hypotensive effects. Am J Kidney Dis 1997, 30:659–664.CrossRefPubMed
27.
Paoletti E, Cassottana P, Bellino D, et al.: Left ventricular geometry and adverse cardiovascular events in chronic hemodialysis patients on prolonged therapy with ACE inhibitors. Am J Kidney Dis 2002, 40:728–736.CrossRefPubMed
28.
•• Tai DJ, Lim TW, James MT, et al.: Cardiovascular effects of angiotensin converting enzyme inhibition or angiotensin receptor blockade in hemodialysis: a meta-analysis. Clin J Am Soc Nephrol 2010, 5:623–630. This up-to-date and well-performed meta-analysis of the few available randomized clinical trials of ACE inhibitors and ARBs in hemodialysis patients found significantly improved left ventricular mass with ACE inhibitor or ARB therapy, but no significant improvement in cardiovascular events.CrossRefPubMed
29.
• Taheri S, Mortazavi M, Shahidi S, et al.: Spironolactone in chronic hemodialysis patients improves cardiac function. Saudi J Kidney Dis Transpl 2009, 20:392–397. This is a small randomized clinical trial of thrice-weekly spironolactone versus placebo in addition to ACE inhibitor or ARB therapy in hemodialysis patients with heart failure. The authors found significantly improved left ventricular mass and ejection fraction in the spironolactone group and no increase in hyperkalemia.PubMed
30.
Pitt B, Zannad F, Remme WJ, et al.: The effect of spironolactone on morbidity and mortality in patients with severe heart failure. Randomized Aldactone Evaluation Study Investigators. N Engl J Med 1999, 341:709–717.CrossRefPubMed
31.
Flather MD, Yusuf S, Kober L, et al.: Long-term ACE-inhibitor therapy in patients with heart failure or left-ventricular dysfunction: a systematic overview of data from individual patients. ACE-Inhibitor Myocardial Infarction Collaborative Group. Lancet 2000, 355:1575–1581.CrossRefPubMed
32.
Lee VC, Rhew DC, Dylan M, et al.: Meta-analysis: angiotensin-receptor blockers in chronic heart failure and high-risk acute myocardial infarction. Ann Intern Med 2004, 141:693–704.PubMed
33.
Rodrigues EJ, Eisenberg MJ, Pilote L: Effects of early and late administration of angiotensin-converting enzyme inhibitors on mortality after myocardial infarction. Am J Med 2003, 115:473–479.CrossRefPubMed
34.
Wanner C, Krane V, Marz W, et al.: Atorvastatin in patients with type 2 diabetes mellitus undergoing hemodialysis. N Engl J Med 2005, 353:238–248.CrossRefPubMed
35.
Fellstrom BC, Jardine AG, Schmieder RE, et al.: Rosuvastatin and cardiovascular events in patients undergoing hemodialysis. N Engl J Med 2009, 360:1395–1407.CrossRefPubMed
36.
Foley RN, Herzog CA, Collins AJ: Blood pressure and long-term mortality in United States hemodialysis patients: USRDS Waves 3 and 4 Study. Kidney Int 2002, 62:1784–1790.CrossRefPubMed
37.
Trespalacios FC, Taylor AJ, Agodoa LY, Abbott KC: Incident acute coronary syndromes in chronic dialysis patients in the United States. Kidney Int 2002, 62:1799–1805.CrossRefPubMed
38.
Kestenbaum B, Gillen DL, Sherrard DJ, et al.: Calcium channel blocker use and mortality among patients with end-stage renal disease. Kidney Int 2002, 61:2157–2164.CrossRefPubMed
39.
Trespalacios FC, Taylor AJ, Agodoa LY, et al.: Heart failure as a cause for hospitalization in chronic dialysis patients. Am J Kidney Dis 2003, 41:1267–1277.CrossRefPubMed
40.
Griffith TF, Chua BS, Allen AS, et al.: Characteristics of treated hypertension in incident hemodialysis and peritoneal dialysis patients. Am J Kidney Dis 2003, 42:1260–1269.CrossRefPubMed
41.
Abbott KC, Trespalacios FC, Agodoa LY, et al.: Beta-blocker use in long-term dialysis patients: association with hospitalized heart failure and mortality. Arch Intern Med 2004, 164:2465–2471.CrossRefPubMed
42.
Ishani A, Herzog CA, Collins AJ, Foley RN: Cardiac medications and their association with cardiovascular events in incident dialysis patients: cause or effect? Kidney Int 2004, 65:1017–1025.CrossRefPubMed
43.
Efrati S, Zaidenstein R, Dishy V, et al.: ACE inhibitors and survival of hemodialysis patients. Am J Kidney Dis 2002, 40:1023–1029.CrossRefPubMed
44.
Fang W, Oreopoulos DG, Bargman JM: Use of ACE inhibitors or angiotensin receptor blockers and survival in patients on peritoneal dialysis. Nephrol Dial Transplant 2008, 23:3704–3710.CrossRefPubMed
45.
Zannad F, Kessler M, Lehert P, et al.: Prevention of cardiovascular events in end-stage renal disease: results of a randomized trial of fosinopril and implications for future studies. Kidney Int 2006, 70:1318–1324.CrossRefPubMed
46.
Zannad F, Kessler M, Grunfeld JP, Thuilliez C: FOSIDIAL: a randomised placebo controlled trial of the effects of fosinopril on cardiovascular morbidity and mortality in haemodialysis patients. Study design and patients’ baseline characteristics. Fundam Clin Pharmacol 2002, 16:353–360.CrossRefPubMed
47.
Takahashi A, Takase H, Toriyama T, et al.: Candesartan, an angiotensin II type-1 receptor blocker, reduces cardiovascular events in patients on chronic haemodialysis—a randomized study. Nephrol Dial Transplant 2006, 21:2507–2512.CrossRefPubMed
48.
Suzuki H, Kanno Y, Sugahara S, et al.: Effect of angiotensin receptor blockers on cardiovascular events in patients undergoing hemodialysis: an open-label randomized controlled trial. Am J Kidney Dis 2008, 52:501–506.CrossRefPubMed
49.
Han SW, Won YW, Yi JH, Kim HJ: No impact of hyperkalaemia with renin-angiotensin system blockades in maintenance haemodialysis patients. Nephrol Dial Transplant 2007, 22:1150–1155.CrossRefPubMed
50.
• Matsumoto Y, Kageyama S, Yakushigawa T, et al.: Long-term low-dose spironolactone therapy is safe in oligoanuric hemodialysis patients. Cardiology 2009, 114:32–38. This prospective study investigated the effect on serum potassium levels from daily spironolactone in oligoanuric hemodialysis patients and found no clinical difference between baseline potassium levels and levels taken over 6 months of follow-up.CrossRefPubMed
Metadata
Title
Should All Hypertensive Dialysis Patients Receive a Blocker of the Renin-Angiotensin System?
Authors
Arjun D. Sinha
Rajiv Agarwal
Publication date
01-10-2010
Publisher
Current Science Inc.
Published in
Current Hypertension Reports / Issue 5/2010
Print ISSN: 1522-6417
Electronic ISSN: 1534-3111
DOI
https://doi.org/10.1007/s11906-010-0137-z

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