Effect of lowering blood pressure on cardiovascular events and mortality in patients on dialysis: a systematic review and meta-analysis of randomised controlled trials

Hiddo J Lambers Heerspink, Toshiharu Ninomiya, Sophia Zoungas, Dick de Zeeuw, Diederick E Grobbee, Meg J Jardine, Martin Gallagher, Matthew A Roberts, Alan Cass, Bruce Neal, Vlado Perkovic, Hiddo J Lambers Heerspink, Toshiharu Ninomiya, Sophia Zoungas, Dick de Zeeuw, Diederick E Grobbee, Meg J Jardine, Martin Gallagher, Matthew A Roberts, Alan Cass, Bruce Neal, Vlado Perkovic

Abstract

Background: Patients undergoing dialysis have a substantially increased risk of cardiovascular mortality and morbidity. Although several trials have shown the cardiovascular benefits of lowering blood pressure in the general population, there is uncertainty about the efficacy and tolerability of reducing blood pressure in patients on dialysis. We did a systematic review and meta-analysis to assess the effect of blood pressure lowering in patients on dialysis.

Methods: We systematically searched Medline, Embase, and the Cochrane Library database for trials reported between 1950 and November, 2008, without language restriction. We extracted a standardised dataset from randomised controlled trials of blood pressure lowering in patients on dialysis that reported cardiovascular outcomes. Meta-analysis was done with a random effects model.

Findings: We identified eight relevant trials, which provided data for 1679 patients and 495 cardiovascular events. Weighted mean systolic blood pressure was 4.5 mm Hg lower and diastolic blood pressure 2.3 mm Hg lower in actively treated patients than in controls. Blood pressure lowering treatment was associated with lower risks of cardiovascular events (RR 0.71, 95% CI 0.55-0.92; p=0.009), all-cause mortality (RR 0.80, 0.66-0.96; p=0.014), and cardiovascular mortality (RR 0.71, 0.50-0.99; p=0.044) than control regimens. The effects seem to be consistent across a range of patient groups included in the studies.

Interpretation: Treatment with agents that lower blood pressure should routinely be considered for individuals undergoing dialysis to reduce the very high cardiovascular morbidity and mortality rate in this population.

Figures

Figure 1
Figure 1
Identification process for eligible studies *Searches on http://www.ClinicalTrials.gov.
Figure 2
Figure 2
Risk of cardiovascular events for blood pressure lowering treatment versus control regimens DBP=diastolic blood pressure. SBP=systolic blood pressure. NA=not applicable. The overall mean difference in systolic and diastolic blood pressure in the active treatment group compared with the control group is also shown. Negative values indicate lower mean follow-up blood pressure in the active treatment group.
Figure 3
Figure 3
Subgroup analyses for the effects of blood pressure lowering agents on cardiovascular events ACE=angiotensin-converting enzyme. ARB=angiotensin-receptor blocker.
Figure 4
Figure 4
Risk of all-cause mortality and cardiovascular mortality for blood pressure lowering treatment versus control regimens NR=not reported.

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