LEFT VENTRICULAR HYPERTROPHY IN DIALYSIS
Choice of Beta Blocker
Objectives
Gain an appreciation and understanding of the management of Left Ventricular Hypertrophy in hemodialysis patients
Review the evidence supporting selection of a beta-blocker in hemodialysis patients
Mr. TC
58 yoa male admitted on 4 Dec ID ht: 172 cm wt: 52 kg BMI: 17.6 CC: cough/SOB, leg swelling HPI: was in Victoria visiting son,
progressively weak over 2 days Previous admission – NRGH Oct 2011
for LLL pneumonia - ICU
Mr. TC
PMH: DM, diabetic retinopathy, hypertension, dyslipidemia, chronic kidney disease - diabetic nephroslcerosis with protinuria, hypokalemia
Surgeries: Bilateral cataract extractions, left finger amputation – saw injury
Allergies: none Compliance: supported by daughter who
helps to organize medications in dosette. No issues
Mr. TC
Social History: Lives at home with spouse and 5
children Chauffeur Born in China and emigrated to Canada
at age 16 Non smoker, non drinker No illicit drug use
Medications PTACondition Medication
Hypertension ramipril 5 mg dailyamlodipine 2.5 mg daily
CKD epoeitin 4000 Units twice weeklyferrous gluconate 300 mg TID
furosemide 20 mg QAM and 40 mg lunch
calcium carbonate 1250 mg TID ACRanitidine 150 mg daily
Medications PTACondition Medication
Diabetes Insulin glargine 6 units HS aspart via sliding scale
Hyperlipidemia Rosuvastatin 10 mg HS
New Diagnoses
Severe CAD – CABG x 3 15 Dec Acute renal insufficiency – start HD
18 Dec for volume control Recurrent bradycardia – code blue X
3 DDDR pacemaker
Left Ventricular Hypertrophy EF 40% prior to CABG, improved to 50%
by 28 Dec
Discharge Medications – 12 Dec
Condition Medication
Hypertension ramipril 5 mg daily
ERSD acetaminophen 325-650 mg Q6H prnepoeitin 6000 Units three times/weekferrous gluconate 125 mg IV Q 2 weekscalcium carbonate 500 mg TID ACpantoprazole 40 mg dailyreplavite 1 tablet dailydousate sodium 100 mg BIDlactulose 15-30 ml BID PRNsennosides 1-2 tabs daily PRNfurosemide 80 mg BID
Discharge MedicationsCondition Medication
Diabetes insulin regular 30 %/NPH 70% 10 units QAM and 12 units QPM
Hyperlipidemia rosuvastatin 10 mg HS
Post CABG ASA 81 mg dailymetoprolol 25 mg BID
Labs 11 Jan
Hg 72 HCT 0.22 MCV 89 Retic 60 Iron 7 Fe Sat 0.18 Ferritin 764 Na 133, K 5.1 Cl 103 CO2 24 Scr 208, EGFR 29 70% Urea
Reduction TSH 2.65 Alb 31 Ca 2.17 PO4 2.07 PTH 6.9
DRPs
Patient is at risk of morbidity and mortality due to left ventricular hypertrophy (LVH)
Patient is anemic and at risk of morbidity and worsening LVH
Patient is hyperphosphatemic and at risk of mineral bone disease
Primary Goals of Therapy
Health Care Team Reduce morbidity and mortality
associated with dialysis and cardiovascular disease
Regress left ventricular hypertrophy Achieve targets for diabetes control
Patient Wishes to be off dialysis Return to work
Left Ventricular Hypertrophy
Occurs in up to 80 % of dialysis patients Major risk factor for mortality
2/3 die from heart failure or sudden death Worsening LVH
Strong predictor of sudden death and arrhythmias
Associated prolonged QT interval and dispersion
Major risk factors Increasing age, hypertension, volume overload
and anemia
LVH Management
Control blood pressure Conerstone is volume control Antihypertensive medications
Correct anemia Maintenance of calcium and
phosphate mineral balance Vascular calcification
Antihypertensive medications
PICO
Patient: Post CABG dialysis patient with left ventricular hypertrophy
Intervention: metoprolol
Comparator: other beta blockers
Outcome: mortality, regression of left ventricular hypertrophy
Literature Search
Search terms Dialysis or hemodialysis, beta blockers
Databases Medline, IPA, CDSR, ACP Journal Club
Limits Humans, English
Results 2 RCTs – 1 retrospective cohort study
.
Cice, G., Ferrara, L., Di Benedetto, a, Russo, P. E., Marinelli, G., Pavese, F., & Iacono, a. (2001). Dilated cardiomyopathy in dialysis patients--beneficial effects of carvedilol: a double-blind, placebo-controlled trial. Journal of the American College of Cardiology, 37(2), 407-11.
Cice 2001
P: N=114, hemodialysis with symptomatic heart failure (NYHA II-III), EF<0.35
I: carvedilol highest tolerated dose to 25 mg BID
C: placebo O: changes in LV end-systolic and end-
diastolic volumes, LVEF and heart failure symptoms after 12 months
ResultsCarvedilol Metoprolol
Basal 12 months
Basal 12 months
LVEDV ml/m2
100 ± 9 94 ± 4 97 ± 8 98 ± 6 P<0.05
LVESV ml/m2
74 ± 8 62 ± 8 72 ± 9 72 ± 8 P<0.05
LVEF % 26 ± 8 36 ± 11 26 ± 8 26 ± 8 P<0.05
Limitations
small numbers, short duration open label no intention to treat excluded recent MI or CABG in past 3
months
Cice, G., Ferrara, L., D’Andrea, A., D’Isa, S., Di Benedetto, A., Cittadini, A., Russo, P. E., et al. (2003). Carvedilol increases two-year survival in dialysis patients with dilated cardiomyopathy. Journal of the American College of Cardiology, 41(9), 1438-1444.
Cice 2003
P: as per 2001 study - continuation I: carvedilol highest tolerated dose to
25 mg BID C: placebo O: primary - as per 2001,
secondary - all-cause mortality, all-cause hospital admission, cardiovascular mortality, acute non-fatal MI and composite
ResultsCarvedilol Metoprolol
Basal 12 month
s
24 month
s
Basal 12 month
s
24 month
s
LVEDV ml/m2
100 ± 9
94 ± 4 94 ± 5 97 ± 8 98 ± 6 100 ± 5
P<0.05
LVESV ml/m2
74 ± 8 62 ± 8 64 ± 6 72 ± 9 72 ± 8 74 ± 3 P<0.05
LVEF % 26 ± 8 36 ± 11
37 ± 10
26 ± 8 26 ± 8 24 ± 10
P<0.05
Results
Limitations
small numbers, short duration open label No intention to treat Excluded recent MI or CABG in past 3
months
Abbott, K. C., Trespalacios, F. C., Agodoa, L. Y., Taylor, A. J., & Bakris, G. L. (2004). β-Blocker Use in Long-term Dialysis Patients: Association With Hospitalized Heart Failure and Mortality. Archives of internal medicine, 164(22), 2465. Am Med Assoc.
Abbott 2004
P: N=2550, peritoneal and hemodialsysis from, DMMS Wave 2, with and without LVH
I/C: risk associations of medication classes used to outcome Chart review – medications at start of study Beta blockers analyzed with subdivision
Cardioselective vs non-cardioselective
O: admission for HF, cardiovascular related death, or death from any cause Medicare claims over 4 years
Demographics
Results
Limitations
Retrospective cohort analysis Hypothesis generating
small numbers, underpowered Did not follow medication changes Did not report on outcome of death
alone Carvedilol not included in study
FDA approved 1997
Recommendation
recommend continue metoprolol follow up echo in 3 months to assess
LVD
Monitoring Plan
What Who When
Blood pressure RN Ongoing
Anemia – by AMP RN, Pharmacist monthly
Signs/Sx heart failure RN, MD, Pharmacist
Ongoing
Metoprolol adverse effects (dizziness, headache, depression, puritis, diaahea, bradycardia, cold extremities)
RN, MD, Pharmacist
Ongoing
QUESTIONS?
References
1. Up to Date
2. Kidney Disease Outcomes Quality Initiative (KDOQI) Guidelines, 2002 The National Kidney Foundation
3. Cice, G., Ferrara, L., Di Benedetto, a, Russo, P. E., Marinelli, G., Pavese, F., & Iacono, a. (2001). Dilated cardiomyopathy in dialysis patients--beneficial effects of carvedilol: a double-blind, placebo-controlled trial. Journal of the American College of Cardiology, 37(2), 407-11.
4. Cice, G., Ferrara, L., D’Andrea, A., D’Isa, S., Di Benedetto, A., Cittadini, A., Russo, P. E., et al. (2003). Carvedilol increases two-year survivalin dialysis patients with dilated cardiomyopathy. Journal of the American College of Cardiology, 41(9), 1438-1444.
5. Abbott, K. C., Trespalacios, F. C., Agodoa, L. Y., Taylor, A. J., & Bakris, G. L. (2004). Β-Blocker Use in Long-term Dialysis Patients: Association With Hospitalized Heart Failure and Mortality. Archives of internal medicine, 164(22), 2465. Am Med Assoc.
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