From the Guidelines
Beta blockers can be used in patients undergoing dialysis, but carvedilol is the preferred agent due to its proven effectiveness in improving left ventricular function and reducing hospitalization, cardiovascular deaths, and total mortality in this population. When considering the use of beta blockers in dialysis patients, it is essential to take into account their pharmacokinetics and potential side effects, as noted in the K/DOQI clinical practice guidelines for cardiovascular disease in dialysis patients 1.
Key Considerations
- Carvedilol has been shown to be effective in a randomized trial in the dialysis population, with benefits comparable to those observed in the general population 1.
- Other beta blockers may have similar effects, but there is a lack of studies to confirm or refute this hypothesis, making carvedilol the preferred choice pending further data 1.
- Special dosing regimens may be necessary to facilitate the delivery of hemodialysis (HD) and ultrafiltration, and the dosing schedules may need to be individualized for each dialysis session to avoid intradialytic hypotension 1.
Benefits and Risks
- Beta blockers are particularly beneficial in dialysis patients with heart failure, coronary artery disease, or arrhythmias, but caution is needed as they may mask hypoglycemia symptoms, exacerbate peripheral vascular disease, and contribute to intradialytic hypotension.
- Blood pressure should be monitored before, during, and after dialysis sessions, and doses may need adjustment based on the dialysis schedule.
- The use of angiotensin-converting enzyme inhibitors, digitalis glycosides, and other agents should be considered in the context of the individual patient's needs and the potential risks and benefits, as outlined in the K/DOQI guidelines 1.
From the Research
Considerations for Using Beta Blockers in Patients Undergoing Dialysis
- The use of beta blockers in patients undergoing dialysis is based on weak evidence due to the lack of sufficient randomized clinical trials 2.
- Beta blockers have been shown to be beneficial in certain populations, such as those with heart failure, with studies demonstrating improved survival and reduced cardiovascular morbidity 2, 3.
- The choice of beta blocker may be important, with some studies suggesting that cardioselective beta blockers with moderate-to-high dialyzability may be the ideal agents in dialysis patients 4.
- However, beta blockers may also have adverse effects, such as intradialytic hypotension, particularly with low dialyzability beta blockers 4.
- Administration of beta blockers after dialysis sessions may be a solution to minimize adverse effects 4.
- Certain beta blockers, such as carvedilol, have been shown to be safe and effective in lowering blood pressure in hemodialysis patients, with no elimination during hemodialysis 5.
Key Findings
- A large cohort of hemodialysis patients with new-onset heart failure showed better survival when treated with carvedilol, bisoprolol, or metoprolol 2.
- A study of 20,064 patients found that metoprolol was associated with less all-cause mortality compared to carvedilol 2.
- Beta blockers were associated with a lower rate of mortality among incident hemodialysis patients with heart failure 3.
- A meta-analysis suggested that high dialyzable beta blockers are correlated with a reduced risk of all-cause mortality and cardiovascular complications compared to low dialyzable beta blockers 4.
Important Considerations
- Beta blockers should be avoided in patients with intradialytic hypotension associated with bradycardia 2.
- The dialyzability of beta blockers may impact patient survival, with high dialyzable beta blockers potentially being more beneficial 4.
- Further studies are needed to fully understand the role of beta blockers in patients undergoing dialysis 4.