Antihypertensive Drug Treatment and the Risk for Intrahemodialysis Hypotension

doi:10.2215/CJN.0000000000000521

. 2024 Oct 1;19(10):1310-1318.

doi: 10.2215/CJN.0000000000000521. Epub 2024 Jul 16.

Antihypertensive Drug Treatment and the Risk for Intrahemodialysis Hypotension

Carmine Zoccali^{1

2

3}, Giovanni Tripepi⁴, Paola Carioni⁵, Edouard L Fu⁶, Friedo Dekker⁷, Vianda Stel^{8

9}, Kitty J Jager^{8

9}, Francesca Mallamaci^{4

10}, Jeffrey L Hymes¹¹, Franklin W Maddux¹¹, Stefano Stuard¹²

Affiliations

¹ Renal Research Institute, New York, New York.
² Institute of Molecular Biology and Genetics (Biogem), Ariano Irpino, Italy.
³ Associazione Ipertensione Nefrologia Trapianto Renale (IPNET), c/o Nefrologia, Grande Ospedale Metropolitano, Reggio Calabria, Italy.
⁴ CNR-IFC, Institute of Clinical Physiology, Research Unit of Clinical Epidemiology, Reggio Calabria, Italy.
⁵ Fresenius Medical Care, Global Medical Office, Crema, Italy.
⁶ Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts.
⁷ Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands.
⁸ Department of Medical Informatics, ERA Registry, Amsterdam UMC location and the University of Amsterdam, Amsterdam, The Netherlands.
⁹ Quality of Care, Amsterdam Public Health, Amsterdam, The Netherlands.
¹⁰ Nephrology, Dialysis and Transplantation Unit, Azienda Ospedaliera "Bianchi-Melacrino-Morelli" Grande Ospedale Metropolitano of Reggio Calabria, Reggio Calabria, Italy.
¹¹ Fresenius Medical Care, Global Medical Office, Waltham, Massachusetts.
¹² Fresenius Medical Care, Global Medical Office, Bad Homburg, Germany.

PMID: 39012707
PMCID: PMC11469783 (available on 2025-10-01)
DOI: 10.2215/CJN.0000000000000521

Antihypertensive Drug Treatment and the Risk for Intrahemodialysis Hypotension

Carmine Zoccali et al. Clin J Am Soc Nephrol. 2024.

. 2024 Oct 1;19(10):1310-1318.

doi: 10.2215/CJN.0000000000000521. Epub 2024 Jul 16.

Authors

Affiliations

¹ Renal Research Institute, New York, New York.
² Institute of Molecular Biology and Genetics (Biogem), Ariano Irpino, Italy.
³ Associazione Ipertensione Nefrologia Trapianto Renale (IPNET), c/o Nefrologia, Grande Ospedale Metropolitano, Reggio Calabria, Italy.
⁴ CNR-IFC, Institute of Clinical Physiology, Research Unit of Clinical Epidemiology, Reggio Calabria, Italy.
⁵ Fresenius Medical Care, Global Medical Office, Crema, Italy.
⁶ Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts.
⁷ Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands.
⁸ Department of Medical Informatics, ERA Registry, Amsterdam UMC location and the University of Amsterdam, Amsterdam, The Netherlands.
⁹ Quality of Care, Amsterdam Public Health, Amsterdam, The Netherlands.
¹⁰ Nephrology, Dialysis and Transplantation Unit, Azienda Ospedaliera "Bianchi-Melacrino-Morelli" Grande Ospedale Metropolitano of Reggio Calabria, Reggio Calabria, Italy.
¹¹ Fresenius Medical Care, Global Medical Office, Waltham, Massachusetts.
¹² Fresenius Medical Care, Global Medical Office, Bad Homburg, Germany.

PMID: 39012707
PMCID: PMC11469783 (available on 2025-10-01)
DOI: 10.2215/CJN.0000000000000521

Abstract

Key Points:

Antihypertensive medications are often used by hemodialysis patients, and intradialytic hypotension is a common complication in these patients.
The study emulates a randomized clinical trial comparing antihypertensive drug treatment for the risk of hemodialysis hypotension in 4072 incident patients.
Compared with calcium antagonists, β and α–β blockers, angiotensin converting enzyme inhibitors or angiotensin II antagonists, and diuretics may increase the risk of hemodialysis hypotension.

Background: Antihypertensive medications are often prescribed to manage hypertension in hemodialysis patients, and intradialytic hypotension (IDH) is a common complication in these patients. We investigated the risk of IDH in incident hemodialysis patients who initiated treatment with antihypertensive drugs in monotherapy.

Methods: The study was conducted as an emulation of a randomized clinical trial in 4072 incident hemodialysis patients who started antihypertensive drug treatment between January 2016 and December 2019. The primary outcome was the occurrence of IDH during hemodialysis sessions. The generalized estimating equation analysis was adjusted by inverse probability treatment weighting.

Results: Calcium channel blocker (CCB) use was associated with an IDH incidence rate of 7.4 events per person-year (95% confidence interval [CI], 6.2 to 8.6). Compared with CCB use, use of β and α–β blockers was strongly associated with a higher likelihood of IDH (odds ratio [OR] [95% CI, 2.27; 1.50 to 3.43]). The use of angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers (OR [95% CI, 1.71; 1.14 to 2.57]) and diuretics (OR [95% CI, 1.52; 1.07 to 2.16]) were also associated with a higher likelihood of IDH compared with CCB use.

Conclusions: The study suggests that using β and α–β blockers, angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers, and diuretics may increase the risk of IDH in hemodialysis patients compared with CCB use.

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Conflict of interest statement

Disclosure forms, as provided by each author, are available with the online version of the article at http://links.lww.com/CJN/B967.

References

1. Assimon MM, Wang L, Flythe JE. Intradialytic hypertension frequency and short-term clinical outcomes among individuals receiving maintenance hemodialysis. Am J Hypertens. 2018;31(3):329–339. doi:10.1093/ajh/hpx186 - DOI - PMC - PubMed
1. Chang TI. Impact of drugs on intradialytic hypotension: antihypertensives and vasoconstrictors. Semin Dial. 2017;30(6):532–536. doi:10.1111/sdi.12633 - DOI - PMC - PubMed
1. Trespalacios FC, Taylor AJ, Agodoa LY, Abbott KC. Incident acute coronary syndromes in chronic dialysis patients in the United States. Kidney Int. 2002;62(5):1799–1805. doi:10.1046/j.1523-1755.2002.00638.x - DOI - PubMed
1. Kestenbaum B, Gillen DL, Sherrard DJ, Seliger S, Ball A, Stehman-Breen C. Calcium channel blocker use and mortality among patients with end-stage renal disease. Kidney Int. 2002;61(6):2157–2164. doi:10.1046/j.1523-1755.2002.00355.x - DOI - PubMed
1. 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(3):1017–1025. doi:10.1111/j.1523-1755.2004.00473.x - DOI - PubMed

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[1] Assimon MM, Wang L, Flythe JE. Intradialytic hypertension frequency and short-term clinical outcomes among individuals receiving maintenance hemodialysis. Am J Hypertens. 2018;31(3):329–339. doi:10.1093/ajh/hpx186 - DOI - PMC - PubMed

[2] Assimon MM, Wang L, Flythe JE. Intradialytic hypertension frequency and short-term clinical outcomes among individuals receiving maintenance hemodialysis. Am J Hypertens. 2018;31(3):329–339. doi:10.1093/ajh/hpx186 - DOI - PMC - PubMed

[3] Chang TI. Impact of drugs on intradialytic hypotension: antihypertensives and vasoconstrictors. Semin Dial. 2017;30(6):532–536. doi:10.1111/sdi.12633 - DOI - PMC - PubMed

[4] Chang TI. Impact of drugs on intradialytic hypotension: antihypertensives and vasoconstrictors. Semin Dial. 2017;30(6):532–536. doi:10.1111/sdi.12633 - DOI - PMC - PubMed

[5] Trespalacios FC, Taylor AJ, Agodoa LY, Abbott KC. Incident acute coronary syndromes in chronic dialysis patients in the United States. Kidney Int. 2002;62(5):1799–1805. doi:10.1046/j.1523-1755.2002.00638.x - DOI - PubMed

[6] Trespalacios FC, Taylor AJ, Agodoa LY, Abbott KC. Incident acute coronary syndromes in chronic dialysis patients in the United States. Kidney Int. 2002;62(5):1799–1805. doi:10.1046/j.1523-1755.2002.00638.x - DOI - PubMed

[7] Kestenbaum B, Gillen DL, Sherrard DJ, Seliger S, Ball A, Stehman-Breen C. Calcium channel blocker use and mortality among patients with end-stage renal disease. Kidney Int. 2002;61(6):2157–2164. doi:10.1046/j.1523-1755.2002.00355.x - DOI - PubMed

[8] Kestenbaum B, Gillen DL, Sherrard DJ, Seliger S, Ball A, Stehman-Breen C. Calcium channel blocker use and mortality among patients with end-stage renal disease. Kidney Int. 2002;61(6):2157–2164. doi:10.1046/j.1523-1755.2002.00355.x - DOI - PubMed

[9] 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(3):1017–1025. doi:10.1111/j.1523-1755.2004.00473.x - DOI - PubMed

[10] 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(3):1017–1025. doi:10.1111/j.1523-1755.2004.00473.x - DOI - PubMed

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Antihypertensive Drug Treatment and the Risk for Intrahemodialysis Hypotension

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Antihypertensive Drug Treatment and the Risk for Intrahemodialysis Hypotension

Authors

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Abstract

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Abstract

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