In Dialysis Patients, Mortality Differs Between Beta-Blockers

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One-year mortality is higher for hemodialysis patients starting carvedilol compared to those starting metoprolol, suggests a study in the American Journal of Kidney Diseases.

The retrospective analysis included 27,064 Medicare patients starting hemodialysis in a large US dialysis organization from 2007 through 2012. All included patients who initiated beta-blocker therapy with metoprolol (64.7% of patients) or carvedilol (35.3%). These two groups were compared for the 1-year outcomes of all-cause mortality, cardiovascular mortality, and intradialytic hypotension, with adjustment for demographic, clinical, laboratory, and dialysis treatment covariates.

Propensity score analysis suggested that the two groups were highly comparable. All-cause mortality per 1000 person-years was 225.1 for patients initiating carvedilol versus 195.8 for those initiating metoprolol: adjusted hazard ratio (HR) 1.08. Cardiovascular mortality was also higher with carvedilol: 108.3 versus 85.1 per 1000 person-years, adjusted HR 1.18.

Subgroup analyses suggested similar mortality differences across major indications for beta-blocker therapy: hypertension, atrial fibrillation, heart failure, and recent myocardial infarction. Carvedilol was also associated with a higher rate of intradialytic hypotension: 57.5 versus 55.2 episodes per 1000 person-treatments, adjusted incidence rate ratio 1.10.

About 80% of beta-blocker prescriptions to US dialysis patients are metoprolol and carvedilol. Despite their recognized pharmacologic and pharmacokinetic differences, there are few data on the comparative safety and efficacy of these two medications.

This large retrospective study suggests higher overall and cardiovascular mortality in hemodialysis patients initiating carvedilol versus metoprolol. Pending definitive randomized trials, the authors suggest that possible adverse hemodynamic effects of carvedilol should be considered when starting beta-blockers in hemodialysis patients [Assimon MM, et al. A comparative study of carvedilol versus metoprolol initiation and 1-year mortality among individuals receiving maintenance hemodialysis. Am J Kidney Dis 2018; DOI:].