Antihypertensive Drug Use in Dialysis Transition May Need Improvement

Only 40% of older patients transitioning to maintenance dialysis were on renin-angiotensin system blockade.
Only 40% of older patients transitioning to maintenance dialysis were on renin-angiotensin system blockade.

A new analysis of trends in antihypertensive medication use among older adults initiating dialysis indicates there is room for improvement.

Using Medicare claims data reported to the US Renal Data System, Tara I. Chang, MD, of Stanford University in Palo Alto, California, and colleagues looked for patterns in antihypertensive medication use among 13,554 low-income patients older than 67 years initiating dialysis from 2008 and 2010.

Prescriptions for antihypertensive drugs increased as patients approached end stage renal disease (ESRD), cresting at 3.4 the quarter before dialysis initiation. That number declined to 2.2 drugs by 2 years after the transition.

Use of angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers (ACEI/ARB) stayed constant at approximately 40%, even among patients with coronary disease and systolic heart failure. Renin-angiotensin system blockade did not correlate with the development of acute kidney injury or hyperkalemia.

Diuretic use declined by 40% with the start of dialysis and continued to dwindle. The researchers further observed that 3- and 4-drug combinations including a diuretic commonly were prescribed before ESRD, whereas 1- and 2-drug β-blocker or calcium-channel blocker–based combinations prevailed afterward.

“We showed that ACEI/ARB and β-blocker use could be improved, particularly in subgroups in whom clinical guidelines recommend first-line treatment, such as patients with coronary heart disease or systolic heart failure,” concluded Dr Chang and colleagues in the Clinical Journal of the American Society of Nephrology, published online ahead of print. “We also show a precipitous drop in diuretic use after incident ESRD, which may not always be appropriate if the patient still has significant residual renal function.”

The study adds information on the management of hypertension during the transition to dialysis. Previous studies and reports offered limited follow-up after dialysis initiation.

As all patients were seniors, the findings may not pertain to the ESRD population as a whole. In addition, insurance claims lacked laboratory or blood pressure results limiting interpretation of clinical relevance.

In an accompanying editorial, Jordana B. Cohen, MD, and Raymond R. Townsend, MD, of the University of Pennsylvania in Philadelphia, noted that many unknowns remain, including the importance of where and when blood pressure is measured and the role of such circumstances as an unexpected abrupt decline in kidney function leading to dialysis initiation.

Sources

1. Chang TI, Zheng Y, Montez-Rath ME, and Winkelmayer WC. Antihypertensive Medication Use in Older Patients Transitioning from Chronic Kidney Disease to End-Stage Renal Disease on Dialysis. Clin J Am Soc Nephrol [Epub ahead of print]. [Epub ahead of print]. doi: 10.2215/CJN.10611015.

2. Jordana B. Cohen and Raymond R. Townsend. Antihypertensive Medication in Patients Pre- and Postdialysis: Still Hazy After All These Years. Clin J Am Soc Nephrol [Epub ahead of print]. doi: 10.2215/CJN.06130616.

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