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Nondialyzable versus Dialyzable β -Blockers in Hemodialysis : A Target Trial Emulation Study
Ali Etemadi1, Sai Liu1, Wolfgang C Winkelmayer2
1Division of Nephrology, Department of Medicine, Stanford University, Stanford, California.
Journal of the American Society of Nephrology : JASN
|May 20, 2026
Summary
Nondialyzable beta-blockers significantly reduced major adverse cardiovascular events (MACE) in hemodialysis patients compared to dialyzable options. This finding is crucial for optimizing cardiovascular care in this vulnerable population.
Area of Science:
- Nephrology and Cardiovascular Medicine
- Pharmacology and Therapeutics
- Clinical Epidemiology
Background:
- Cardiovascular outcomes in hemodialysis patients treated with beta-blockers are unclear due to conflicting observational data and challenges in clinical trials.
- Prescribing patterns for beta-blockers vary significantly among clinicians and regions, highlighting a need for evidence-based guidance.
Purpose of the Study:
- To investigate the comparative effectiveness of nondialyzable versus dialyzable beta-blockers on major adverse cardiovascular events (MACE) in patients initiating hemodialysis.
- To address the uncertainty surrounding beta-blocker selection in hemodialysis patients and inform clinical practice.
Main Methods:
- Utilized the US Renal Data System to identify hemodialysis patients on beta-blockers at treatment initiation.
- Classified patients into nondialyzable and dialyzable beta-blocker groups, using geographical prescription variations as an instrumental variable.
- Employed instrumental variable g-estimation to assess the effect of beta-blocker type on MACE (myocardial infarction, stroke, all-cause mortality) at 6 months, 1 year, and 3 years.
Main Results:
- A cohort of 40,313 patients was analyzed, with 25,720 MACE recorded over 3 years; over 42% occurred within the first 6 months.
- Nondialyzable beta-blockers were associated with a significantly lower risk of MACE at all follow-up points (6 months, 1 year, 3 years) compared to dialyzable beta-blockers.
- Individual MACE components, including myocardial infarction, stroke, and all-cause mortality, showed similar risk reduction patterns with nondialyzable beta-blockers.
Conclusions:
- Nondialyzable beta-blockers demonstrate a reduced risk of major adverse cardiovascular events in hemodialysis patients.
- The benefits of nondialyzable beta-blockers extend to the critical early period following hemodialysis initiation, offering improved cardiovascular protection.
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