CARDIOVASCULAR PROTECTION WITH ANTIHYPERTENSIVE THERAPY IN HEMODIALYSIS PATIENTS: SYSTEMATIC REVIEW AND META-ANALYSIS OF RANDOMIZED CONTROLLED TRIALS

Objective: Large observational studies have shown a paradoxical reverse association between blood pressure (BP) and risk of all-cause mortality in hemodialysis patients, raising concerns on whether hypertension is truly an independent risk factor in this population. The available randomized controlled trials that evaluated the efficacy of antihypertensive therapy in hemodialysis patients have been few, have included small sample sizes with insufficient number of cardiovascular events and have provided contradictory results. Accordingly, the aim of this meta-analysis is to explore the effect of active treatment with antihypertensive drugs relative to placebo on cardiovascular outcomes and all-cause mortality in the hemodialysis population. Design and method: We searched MedLine/PubMed and Cochrane Central databases from inception through June 2024 aiming to identify RCTs comparing the efficacy of antihypertensive treatment relative to placebo or no add-on therapy in patients on hemodialysis. RCTs were eligible, if they were designed to explore treatment effects on fatal or non-fatal cardiovascular events as a primary efficacy outcome. Results: A total of 9 RCTs incorporating data from 2,340 hemodialysis patients met the prespecified inclusion/exclusion criteria and were inserted in quantitative data synthesis. As compared with placebo or no add-on therapy, active treatment with antihypertensive drugs was associated with a 27.8% reduction in the risk of fatal or non-fatal cardiovascular events using a fixed-effects model [relative risk (RR): 0.722; 95% confidence interval (CI): 0.618-0.845] and with a 34.7% relative risk reduction using a random-effects model (RR: 0.653; 95% CI: 0.502-0.849). In addition, relative to placebo or no add-on therapy, active treatment with antihypertensive medications was associated with a 29.4% reduction in the risk of death from any cause using a fixed-effects model (RR: 0.706; 95% CI: 0.592-0.843) and with a 35.6% reduction using a random-effects model (RR: 0.644; 95% CI: 0.469-0.833). Conclusions: This updated meta-analysis of RCTs shows that among patients on hemodialysis, deliberate BP lowering with the use of antihypertensive medications is associated with significant reductions in the risk of major adverse cardiovascular events and all-cause mortality.