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Effect of angiotensin receptor blockers on cardiovascular events in patients undergoing hemodialysis: an open-label
Hiromichi Suzuki1, Yoshihiko Kanno, Soichi Sugahara
1Department of Nephrology, School of Medicine, Faculty of Medicine, Saitama Medical University, Saitama, Japan. iromichi@saitama-med.ac.jp
Insights
Angiotensin receptor blockers (ARBs) significantly reduced cardiovascular disease (CVD) events in hemodialysis (HD) patients. While promising, larger studies are needed to confirm these findings for patients with kidney failure on HD.
Area of Science:
- Nephrology
- Cardiology
- Pharmacology
Background:
- Cardiovascular disease (CVD) is the primary cause of death in hemodialysis (HD) patients.
- Angiotensin receptor blockers (ARBs) are known to reduce CVD events in diabetic patients with chronic kidney disease.
- The efficacy of ARBs in HD patients with kidney failure remains unknown.
Purpose of the Study:
- To investigate the effect of ARBs on CVD events in patients undergoing long-term HD.
- To evaluate ARBs as a potential intervention for reducing cardiovascular mortality in this high-risk population.
Main Methods:
- An open-label randomized trial was conducted.
- 180 patients undergoing HD (30-80 years old) received ARBs (valsartan, candesartan, losartan), while 180 served as controls.
- Patients were stratified by sex, age, systolic blood pressure, and diabetes.
Main Results:
- Treatment with ARBs was associated with a significant reduction in fatal and nonfatal CVD events (HR, 0.51; P = 0.002).
- The ARB group experienced 19% CVD events compared to 33% in the non-ARB group.
- All-cause mortality showed a trend towards reduction in the ARB group (HR, 0.64; P = 0.1).
Conclusions:
- ARBs may be effective in reducing nonfatal CVD events for patients on long-term HD.
- Limitations include a small sample size and open-label design, suggesting the observed effect might be spurious.
- Larger, placebo-controlled trials are necessary to validate these findings.
Background:
Cardiovascular disease is the leading cause of mortality in patients with kidney failure treated with hemodialysis (HD). Although angiotensin receptor blockers (ARBs) reduce cardiovascular disease (CVD) events in patients with diabetes and chronic kidney disease, their effect in patients with kidney failure on HD therapy is not known.
Study Design:
Open-labeled randomized trial.
Setting & Participants:
Patients aged 30 to 80 years receiving HD 2 to 3 times weekly for 1 to 5 years at 5 university-affiliated dialysis centers.
Interventions:
Treatment with ARBs (valsartan, candesartan, and losartan) versus without ARBs after stratification by sex, age, systolic blood pressure, and diabetes.
Outcomes:
The primary end point is the development of fatal and nonfatal CVD events, defined as the composite of CVD death, myocardial infarction, stroke, congestive heart failure, coronary artery bypass grafting, or percutaneous coronary intervention. The secondary end point is all-cause death.
Results:
366 subjects initially were randomly assigned to an ARB or no ARB (control), but after a run-in phase, 180 were retained in each group. Mean age was 60 years, 59% were men, 51% had diabetes, and mean predialysis systolic blood pressure was 154 mm Hg. There were 93 fatal or nonfatal CVD events (52%); 34 (19%) in the ARB group and 59 (33%) in the non-ARB group. After adjustment for age, sex, diabetes, systolic blood pressure, and center, treatment with an ARB was independently associated with reduced fatal and nonfatal CVD events (hazard ratio, 0.51; 95% confidence interval, 0.33 to 0.79; P = 0.002). There were 63 deaths (35%); 25 (14%) in the ARB group and 38 (21%) in the non-ARB group. After adjustment, all-cause mortality differed between the 2 groups (hazard ratio, 0.64; 95% confidence interval, 0.39 to 1.06; P = 0.1).
Limitations:
Because of the small sample size of this trial, the large effect may be a spurious finding. Use of an open-label design and 3 different agents in the ARB group might have influenced results.
Conclusion:
Use of an ARB may be effective in reducing nonfatal CVD events in patients undergoing long-term HD. A larger study is required to confirm these results.
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