Rajiv Agarwal fights hypertension in the dialysis unit.
The late breaking trials continued with Rajiv Agarwal’s randomized controlled retrial of different blood pressure therapy in the dialysis unit. Agarwal has been out in front on this subject for awhile. He did some landmark work showing that blood pressure control was not another case of reverse epidemiology in the dialysis unit and also showed the utility of ambulatory and home blood pressure monitoring for dialysis patients (http://www.uphs.upenn.edu/renal/important%20pdf%20II/HTN%20in%20HD%20patients.pdf and http://hyper.ahajournals.org/content/55/3/762.short). Agarwal discussed that most of the hypertension in dialysis patients is volume related, but that even after you correct this there is some residual hypertension. He designed a trial to see how to optimally treat that.
This trial enrolled hypertensive dialysis patients; they used 48 hour ambulatory BP measurements to ensure hypertension for enrollment. The trial pitted atenolol against lisinopril against each other. Both of these drugs are renally excreted so Agarwal was able to dose them after each dialysis session only 3 days a week. Direct observational treatment, like tuberculosis but for hypertension. He randomized 200 patients. Only 104 completed the trial. They had heavy patient drop out, especially in the lisinopril group. They saw more BP lowering affect with atenolol, about 5.6 mmHg systolic. This was seen at 3 months and continued to the end of the trial. The improved blood pressure in the atenolol group was despite more weight loss (more aggressive UF I imagine) and more antihypertensive drugs with lisinopril.
The real meat of the study was the CV event rate, which was more than double with lisinopril compared to atenolol, IRR = 2.36, P=0.001. Maybe the most important slide was titled “Nearly all SAEs more in lisinopril.” The details:
- CHF Hospitalization IRR 3.13 P=0.02
- All cause Hospitalization IRR 1.61 P<0.01
- All cause SAE IRR 1.47 P<0.001
- Hypertensive Crisis IRR 3.81 P=0.03
- Hyperkalemia IRR 3.38 P=0.05
Dr. Agarwal was unable to assess if this was due to harm from lisinopril or harm from a lack of beta-blocker. Overall, this was an interesting study and really lays bare the fact that we have almost no RCT data on what to do about blood pressure control in dialysis patients. I applaud this effort and hope to see more trials help guide nephrologists in treating this vital sign in dialysis.
Post written by Dr. Joel Topf, eAJKD Advisory Board member.