Atenolol or Lisinopril: and the winner is….HDPAL update

Hypertension in dialysis patients is hard to manage. In over 90% of the cases, the cause of volume. Salt and water intake and inability for fluid removal remains the most like cause of HTN in ESRD. Few cases are renin mediated as well.  Which anti hypertensive medications have the best effect in the few cases of HTN that is not treated with volume removal?  ACEI/ARB would be the most obvious choice. Randomized trials in non ESRD hypertensive patients have shown that LVH is significantly improved and preventing cardiac morbidity and mortality with ACEI/ARBs compared to Beta Blockers.  A recent study in NDT 2014 by Agarwal et al. was a randomized trial of atenolol and lisinopril in ESRD patients(HDPAL).

Results:

1.       Monthly blood pressures were higher in ACEI group after initiation of therapy

2.       More serious cardiovascular events occurred in ACEI group compared to the atenolol group

3.       All cause hospitalizations were higher in ACEI group as well

4.       Finally, LVH had improvement equally in both groups

5.       These results hold most true for black patients.

Some interesting points:

1.       This is the first study to look at head to head drug comparison in ESRD patients with BP management

2.       Counter to what may have shown in non ESRD patients, this study showed that atenolol was better.

3.       Atenolol is renally cleared of all the beta blockers and number of patients that are non anuric might matter as it might have had more clearance and less of a heart rate effect. Interestingly, that variable was well matched as well.

4.       Although not sure of significance, less atenolol patients had coronary artery disease and significant number of them had re vascularization procedures. This may be a big weakness as going into the study, there were less sicker patients in the ACEI arm from a cardiac perspective.

5.       But to counter balance that, there were more males in the atenolol arm compared to ACEI arm

6.       Increased fractures were noted with atenolol arm- perhaps again getting into the renal clearance effect perhaps and effect on heart rate and causing blocks

7.       There was no placebo arm and most patients were black – perhaps hard then to generalize to all races.

8.       Using BP monitoring interdialytic ambulatory BP monitors was a strength

9.       Interestingly, it says at the end of the manuscript: received for publication Dec 2^nd 2013 and accepted in revised form on Dec 4^th 2013.  That is strange that a paper can get peer reviewed, revised and gotten back for accepted form in 2 days. Hopefully that was a typo.