Abstract
BackgroundSeveral observational studies have evaluated the effect of a single exposure window with blood pressure (BP) medications on outcomes in incident dialysis patients, but whether BP medication prescription patterns remain stable or a single exposure window design is adequate to evaluate effect on outcomes is unclear.MethodsWe described patterns of BP medication prescription over 6 months after dialysis initiation in hemodialysis and peritoneal dialysis patients, stratified by cardiovascular comorbidity, diabetes, and other patient characteristics. The cohort included 13,072 adult patients (12,159 hemodialysis, 913 peritoneal dialysis) who initiated dialysis in Dialysis Clinic, Inc., facilities January 1, 2003-June 30, 2008, and remained on the original modality for at least 6 months. We evaluated monthly patterns in BP medication prescription over 6 months and at 12 and 24 months after initiation.ResultsPrescription patterns varied by dialysis modality over the first 6 months; substantial proportions of patients with prescriptions for beta-blockers, renin angiotensin system agents, and dihydropyridine calcium channel blockers in month 6 no longer had prescriptions for these medications by month 24. Prescription of specific medication classes varied by comorbidity, race/ethnicity, and age, but little by sex. The mean number of medications was 2.5 at month 6 in hemodialysis and peritoneal dialysis cohorts.ConclusionsThis study evaluates BP medication patterns in both hemodialysis and peritoneal dialysis patients over the first 6 months of dialysis. Our findings highlight the challenges of assessing comparative effectiveness of a single BP medication class in dialysis patients. Longitudinal designs should be used to account for changes in BP medication management over time, and designs that incorporate common combinations should be considered.
Highlights
Several observational studies have evaluated the effect of a single exposure window with blood pressure (BP) medications on outcomes in incident dialysis patients, but whether BP medication prescription patterns remain stable or a single exposure window design is adequate to evaluate effect on outcomes is unclear
Peritoneal dialysis patients were younger, less likely to be black, less likely to have ESRD caused by diabetes or hypertension, less likely to have cardiovascular conditions or diabetes, and more likely to have ESRD caused by glomerulonephritis; they had lower systolic BP and higher albumin and hemoglobin (Table 1)
The mean (± SD) number of prescribed medications was 2.8 ± 1.4 for peritoneal dialysis and 2.3 ± 1.4 for hemodialysis patients in month 1, but by month 6 the mean was 2.5 for both cohorts; the mean over the first 6 months of dialysis increased for hemodialysis and decreased for peritoneal dialysis patients
Summary
Several observational studies have evaluated the effect of a single exposure window with blood pressure (BP) medications on outcomes in incident dialysis patients, but whether BP medication prescription patterns remain stable or a single exposure window design is adequate to evaluate effect on outcomes is unclear. Hypertension, congestive heart failure (CHF), and atherosclerotic heart disease occur in 85%, 32%, and 21%, respectively, of incident dialysis patients [1]. Two limited in their ability to conclusively support use of specific agents because of small sample sizes and heterogeneity of study designs. Observational studies to date have been limited; some were conducted with prevalent patients with varying dialysis duration and comorbid conditions, possibly leading to problems with selection bias and confounding by indication. These concerns can be mitigated somewhat using incident populations. Understanding utilization patterns of BP medications in the months after dialysis initiation is imperative before appropriate designs for future studies can be determined
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