β-Blocker Use and Risk of Mortality in Heart Failure Patients Initiating Maintenance Dialysis

Comparison of β-blocker agents and mortality in maintenance hemodialysis patients: an international cohort study

Background

Despite a lack of clinical trial data, β-blockers are widely prescribed to dialysis patients. Whether specific β-blocker agents are associated with improved long-term outcomes compared with alternative β-blocker agents in the dialysis population remains uncertain.

Methods

We analyzed data from an international cohort study of 10 125 patients on maintenance hemodialysis across 18 countries that were newly prescribed a β-blocker medication within the Dialysis Outcomes and Practice Patterns Study (DOPPS). The following β-blocker agents were compared: metoprolol, atenolol, bisoprolol and carvedilol. Multivariable Cox proportional hazards models were used to estimate the association between the newly prescribed β-blocker agent and all-cause mortality. Stratified analyses were performed on patients with and without a prior history of cardiovascular disease.

Results

The mean (standard deviation) age in the cohort was 63 (15) years and 57% of participants were male. The most commonly prescribed β-blocker agent was metoprolol (49%), followed by carvedilol (29%), atenolol (11%) and bisoprolol (11%). Compared with metoprolol, atenolol {adjusted hazard ratio (HR) 0.77 [95% confidence interval (CI) 0.65-0.90]} was associated with a lower mortality risk. There was no difference in mortality risk with bisoprolol [adjusted HR 0.99 (95% CI 0.82-1.20)] or carvedilol [adjusted HR 0.95 (95% CI 0.82-1.09)] compared with metoprolol. These results were consistent upon stratification of patients by presence or absence of a prior history of cardiovascular disease.

Conclusions

Among patients on maintenance hemodialysis who were newly prescribed β-blocker medications, atenolol was associated with the lowest mortality risk compared with alternative agents.

The Effect of Antihypertensive Therapy on Skeletal Muscle Mass and Bone Mineral Density in Patients With End-Stage Kidney Disease

OBJECTIVE

Sarcopenia and osteoporosis substantially influence health and lifespan. However, the variables affecting skeletal muscle mass (SMM) or bone mineral density (BMD) remain unknown.

DESIGN AND METHODS

From August 1, 2018 to July 31, 2019, we conducted a single-center, observational cohort study with 291 Japanese adult patients on maintenance hemodialysis due to end-stage kidney disease, who had their femoral neck BMD measured using dual-energy X-ray absorptiometry. After 1-year follow-up, we measured annual changes of BMD (ΔBMD) and SMM (ΔSMM), which were calculated through a modified creatinine index (mg/kg/day) using age, sex, serum creatinine, and single-pooled Kt/V for urea. The factors associated with ΔSMM/ΔBMD or progressive loss of SMM/BMD, defined as ΔSMM/ΔBMD < 0 per year, respectively, were analyzed with multivariable, linear regression or logistic regression models.

RESULTS

The median age of the patients was 66 years and 33% were female. Dialysis vintage and β-blocker-use were inversely correlated to ΔSMM. In comparison to nonusers, β-blockers users had 2.5-fold higher SMM loss odd ratios [95% confidence interval, 1.3-4.8]. The risk for SMM loss caused by β-blockers was not increased in users of renin-angiotensin system inhibitors. The ΔBMD was negatively correlated to the usage of calcium channel blockers. The risk of developing osteosarcopenia, which was defined as annual loss of both SMM and BMD, increased in calcium channel blockers users.

CONCLUSIONS

The use of β-blockers is associated with an elevated risk of developing sarcopenia, whereas renin-angiotensin system inhibitors may minimize this effect in patients with end-stage kidney disease. Use of calcium channel blocker therapy was associated with a faster decline of BMD.

Prognostic Impact of Early Administration of β-Blockers in Critically Ill Patients with Acute Myocardial Infarction

In critically ill patients with acute myocardial infarction (AMI), the relationship between the early administration of β-blockers and the risks of in-hospital and long-term mortality remains controversial. Furthermore, there are conflicting evidences for the efficacy of the early administration of intravenous followed by oral β-blockers in AMI. We conducted a retrospective analysis of critically ill patients with AMI who received the early administration of β-blockers within 24 hours of admission. The data were extracted from the Medical Information Mart for Intensive Care IV database. We enrolled 2467 critically ill patients with AMI in the study, with 1355 patients who received the early administration of β-blockers and 1112 patients who were non-users. Kaplan-Meier survival analysis and Cox proportional hazards models showed that the early administration of β-blockers was associated with a lower risk of in-hospital mortality (adjusted hazard ratio [aHR] 0.52; 95% confidence interval [95%CI] 0.42-0.64), 1-year mortality (aHR 0.54, 95%CI 0.47-0.63), and 5-year mortality (aHR 0.60, 95%CI 0.52-0.69). Furthermore, the early administration of both oral β-blockers and intravenous β-blockers followed by oral β-blockers may reduce the mortality risk, compared with non-users. The risks of in-hospital and long-term mortality were significantly decreased in patients who underwent revascularization with the early administration of β-blockers. We found that the early administration of β-blockers could lower the risks of in-hospital and long-term mortality. Furthermore, the early administration of both oral β-blockers and intravenous β-blockers followed by oral β-blockers may reduce the mortality risk, compared with non-users. Notably, patients who underwent revascularization with the early administration of β-blockers showed the lowest risks of in-hospital and long-term mortality.

The Possible Effect of β-Blocker Use on the Circulating MMP-2/TIMP-2 System in Patients with Chronic Kidney Disease on Conservative Treatment

Background: The purpose of the study was to determine whether the use of β-adrenoceptor antagonists (β-blockers) can affect metalloproteinase 2 (MMP-2) and its tissue inhibitor (TIMP-2) in patients with chronic kidney disease (CKD) on conservative treatment. Methods: The circulating MMP-2/TIMP-2 system, proinflammatory cytokines (tumor necrosis factor-alpha (TNF-α) and interleukin-6 (IL-6), and the marker of oxidative stress-Cu/Zn superoxide dismutase (Cu/Zn SOD)-were measured in 23 CKD patients treated with β-blockers [β-blockers (+)] and in 27 CKD patients not receiving the above medication [β-blockers (-)]. Results: The levels of MMP-2, TIMP-2, and IL-6 were significantly lower in the β-blockers (+) than in the β-blockers (-) group, whereas Cu/Zn SOD concentrations were not affected by β-blocker use. There was a strong, independent association between MMP-2 and TIMP-2 in both analyzed patient groups. In the β-blockers (+) group, MMP-2 levels were indirectly related to the signs of inflammation, whereas in the β-blockers (-) group, the alterations in the MMP-2/TIMP-2 system were associated with the oxidative stress marker and CKD etiology. Conclusions: This study is the first to suggest that the use of β-blockers was associated with the reduction in IL-6 and the MMP-2/TIMP-2 system in CKD, providing a pharmacological rationale for the use of β-blockers to reduce inflammation and abnormal vascular remodeling in CKD.

Association between beta-blocker utilization and heart failure mortality in the peritoneal dialysis population: a cohort study

Background

The prognostic significance of beta(β)-blocker therapy in patients at end-stage renal disease, specifically those receiving peritoneal dialysis (PD) and presenting with heart failure, remains inadequately elucidated due to limited research conducted thus far.

Methods

A retrospective analysis was performed on a cohort comprising 608 patients receiving PD between September 2007 and March 2019, with a subsequent follow-up period extending until December 2020. Cox regression and propensity score matching weighted analysis was used to model adjusted hazard ratios for β-blocker use with heart failure-related mortality. Competing risk analysis and subgroup analysis were carried out to further elucidate the correlation.

Results

β-blockers were prescribed for 56.1% of the peritoneal dialysis patients. Heart failure occurred in 43.4% of the total population and 15.5% of deaths were due to heart failure. The prescription of β-blockers was associated with a 43% lower adjusted hazard ratio (HR) for heart failure death within the cohort (95% confidence interval [CI] = 0.36-0.89; P = 0.013). Even after accounting for competing risk events, patients in the group using β-blockers demonstrated a significantly lower cumulative risk of heart failure-related mortality compared to those not using β-blockers (P = 0.007). This protective effect of β-blockers was also observed in subgroup analyses. Conversely, β-blocker use had no statistically significant associations with all-cause mortality.

Conclusion

The use of β-blockers was associated with a reduced risk of heart failure-related mortality in the PD population. Future randomized clinical trials are warranted to confirm the beneficial effect of β-blockers in the context of PD.

β-Blockers could improve the 28-day and 3-year survival of patients with end-stage renal disease: a retrospective cohort study

BACKGROUND

Dialysis or non-dialysis end-stage renal disease (ESRD) patients are accompanied by cardiovascular disease (CVD) or hypertension. We aimed to study the effect of a common treatment for CVD, β-blockers, on the survival of ESRD patients, improving their prognosis from the perspective of drug therapy.

METHODS

It was a retrospective cohort study using the Medical Information Mart for Intensive Care dataset. ESRD patients in the intensive care unit from June 2001 to October 2012 were included. We examined the effect of using versus not using β-blockers in the overall population and subgroups with the risk of 28-day and 3-year mortality through Cox proportional hazards models and Kaplan-Meier curves.

RESULTS

A total of 1639 participants were included with 371 (22.64%) β-blockers users. There were 315 (19.22%) 28-day and 970 (59.18%) 3-year mortality events during follow-up. Using β-blockers in overall ESRD patients could reduce all-cause 28-day mortality [adjusted hazard ratio (HR) 0.450, 95% confidence interval (CI) 0.325-0.624] and 3-year mortality (adjusted HR 0.695, 95% CI 0.589-0.821). This result was consistent among subgroups (ESRD without hypertension: adjusted HR 0.412, 95% CI 0.289-0.588; with CVD: adjusted HR 0.478, 95% CI 0.321-0.711; without CVD: adjusted HR 0.448, 95% CI 0.248-0.810; with dialysis: adjusted HR 0.471, 95% CI 0.320-0.694) in 28-day mortality, and the 3-year mortality was consistent. In ESRD patients with hypertension and without dialysis subgroups, β-blockers had no effect on survival.

CONCLUSION

Using β-blockers could reduce the risk of 28-day and 3-year mortality in ESRD patients, including those with CVD. This study provided a reference for the treatment of β-blockers in patients with ESRD.

Why is Intradialytic Hypotension the Commonest Complication of Outpatient Dialysis Treatments?

Intradialytic hypotension (IDH) is the most frequent complication of hemodialysis (HD) treatments with a frequency of 10% to 12% for patients with chronic kidney disease attending for outpatient treatments and is associated with both temporary ischemic stress to vital organs, including the heart and brain, and increased patient mortality. Although there have been many different definitions of IDH over the years, an absolute nadir systolic blood pressure (SBP) has the strongest association with patient outcomes. The unifying pathophysiology is one of reduced effective blood volume, resulting in lower plasma tonicity, and if this cannot be adequately compensated for by activation of neurohumeral systems, then arteriolar tone and blood pressure fall. The risk factors for developing IDH are numerous, ranging from patient-related factors, including age and comorbidity with reduced cardiac reserve, to patient compliance with dietary and lifestyle advice, to reactions with the extracorporeal circuit and medications, choice of dialysate composition and temperature, setting of postdialysis target weight, ultrafiltration rate, and profiling. Advances in dialysis machine technology by providing real time estimates of the effective circulating volume and adjusting dialysate composition to maintain vascular tonicity are being developed, but currently require more sophisticated biofeedback loops to be clinically effective in preventing IDH. While awaiting advances in artificial intelligence, the clinician continues to rely on patient education to limit interdialytic weight gains, frequent assessment of the postdialysis target weight, adjusting dialysate composition and temperature, introducing convective therapies to increase thermal losses, and altering dialysis session duration and frequency to reduce ultrafiltration rate requirements.

Chronic Kidney Disease as a Comorbidity in Heart Failure

Heart failure (HF) is one of the greatest problems in healthcare and it often coexists with declining renal function. The pathophysiology between the heart and the kidneys is bidirectional. Common mechanisms leading to the dysfunction of these organs result in a vicious cycle of cardiorenal deterioration. It is also associated with difficulties in the treatment of aggravating HF and chronic kidney disease (CKD) and, as a consequence, recurrent hospitalizations and death. As the worsening of renal function has an undeniably negative impact on the outcomes in patients with HF, searching for new treatment strategies and identification of biomarkers is necessary. This review is focused on the pathomechanisms in chronic kidney disease in patients with HF and therapeutic strategies for co-existing CKD and HF.

Managing Heart Failure in Patients on Dialysis: State-of-the-Art Review

Heart failure (HF) and end-stage kidney disease (ESKD) frequently coexist; 1 comorbidity worsens the prognosis of the other. HF is responsible for almost half the deaths of patients on dialysis. Despite patients' with ESKD composing an extremely high-risk population, they have been largely excluded from landmark clinical trials of HF, and there is, thus, a paucity of data regarding the management of HF in patients on dialysis, and most of the available evidence is observational. Likewise, in clinical practice, guideline-directed medical therapy for HF is often down-titrated or discontinued in patients with ESKD who are undergoing dialysis; this is due to concerns about safety and tolerability. In this state-of-the-art review, we discuss the available evidence for each of the foundational HF therapies in ESKD, review current challenges and barriers to managing patients with HF on dialysis, and outline future directions to optimize the management of HF in these high-risk patients.

Effects of sacubitril/valsartan in ESRD patients undergoing hemodialysis with HFpEF

Introduction

Heart failure with preserved ejection fraction (HFpEF), which is a common co-morbidity in patients with maintenance hemodialysis (MHD), results in substantial mortality and morbidity. However, there are still no effective therapeutic drugs available for HFpEF currently. Sacubitril/valsartan has been shown to significantly improve clinical outcomes and reverse myocardial remodeling among patients with heart failure with reduced ejection fraction (HFrEF). The effect of sacubitril/valsartan in MHD patients with HFpEF remains unclear. Our study was designed to assess the efficacy and safety of sacubitril/valsartan in MHD patients with HFpEF.

Methods

A total of 247 MHD patients with HFpEF treated with sacubitril/valsartan were included in this retrospective study. Patients were followed up regularly after medication treatment. The alterations in clinical, biochemical, and echocardiographic parameters before and after taking sacubitril/valsartan were collected. In addition, the safety of the sacubitril/valsartan treatment was also assessed. Among those 247 patients with MHD, 211 patients were already in treatment with angiotensin converting enzyme inhibitors (ACEi)/angiotensin receptor blockers (ARBs) before being treated with sacubitril/valsartan. We also performed an analysis to compare the differences between the 211 patients who had previously received ACEi/ARB treatment and the 36 patients who were sacubitril/valsartan naive.

Results

Among those 247 patients with MHD, compared with baseline levels, systolic blood pressure (BP) (149.7 ± 23.6 vs. 137.2 ± 21.0 mmHg, P < 0.001), diastolic BP (90.2 ± 16.1 vs. 84.5 ± 14.1 mmHg, P < 0.001), heart rate (83.5 ± 12.5 vs. 80.0 ± 8.7 bpm, P < 0.001), N-terminal B-type natriuretic peptide precursor (NT-proBNP) [29125.0 (11474.5, 68532.0) vs. 12561.3 (4035.0, 37575.0) pg/ml, P < 0.001], and cardiac troponin I [0.044 (0.025, 0.078) vs. 0.0370 (0.020, 0.064) μg/L, P = 0.009] were markedly decreased after treatment with sacubitril/valsartan. New York Heart Association (NYHA) functional class showed a notable trend of improvement after 3–12 months of follow-up. Echocardiographic parameters including left ventricular posterior wall thickness (LVPWT) (11.8 ± 2.0 vs. 10.8 ± 1.9 mm, P < 0.001), intraventricular septal thickness in diastole (11.8 ± 2.0 vs. 11.2 ± 2.0 mm, P < 0.001), left ventricular end-diastolic diameter (53.8 ± 6.9 vs. 51.2 ± 7.1 mm, P < 0.001), left atrial diameter (LAD) (40.5 ± 6.2 vs. 37.2 ± 7.2 mm, P < 0.001), left ventricular end-diastolic volume (LVEDV) [143.0 (111.5, 174.0) vs. 130.0 (105.0, 163.0) ml, P < 0.001], left ventricular end-systolic volume (LVESV) [57.0 (43.0, 82.5) vs. 48.0 (38.0, 74.0) ml, P < 0.001], and pulmonary arterial systolic pressure [39.0 (30.5, 50.0) vs. 28.0 (21.0, 37.5) mmHg, P < 0.001] were significantly reduced after initiating the treatment of sacubitril/valsartan. The parameters of left ventricular diastolic function including E/A ratio [0.8 (0.7, 1.3) vs. 0.9 (0.8, 1.3), P = 0.008], maximal tricuspid regurgitation velocity [2.7 (2.5, 3.2) vs. 2.4 (2.0, 2.8) m/s, P < 0.001], septal e’wave velocity (8.0 ± 0.6 vs. 8.2 ± 0.5 cm/s, P = 0.001), lateral e’ wave velocity (9.9 ± 0.8 vs. 10.2 ± 0.7 cm/s, P < 0.001), E/e’ [8.3 (6.4, 11.8) vs. 7.2 (6.1, 8.9), P < 0.001], and left atrial volume index (37.9 ± 4.2 vs. 36.4 ± 4.1 ml/m², P < 0.001) were significantly improved by sacubitril/valsartan. Among 211 patients who were already in treatment with ACEi/ARB and 36 patients who were sacubitril/valsartan naive, the improvement of cardiac function demonstrated by clinical outcomes and echocardiographic parameters were similar to the previous one of the 247 MHD patients with HFpEF. During the follow-up, none of the patients showed severe adverse drug reactions.

Conclusion

Our study suggested that sacubitril/valsartan treatment in MHD patients with HFpEF was effective and safe.