Antihypertensive Medication Exposure and Cardiovascular Outcomes in Hemodialysis Patients
Antihypertensive Medication Exposure and Cardiovascular Outcomes in Hemodialysis Patients
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DOI：
10.1159/000365255
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发表时间：
2014-01-01
影响因子：
4.2
通讯作者：
Mahnken, Jonathan D.
中科院分区：
文献类型：
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作者：
Shireman, Theresa I.;Phadnis, Milind A.;Mahnken, Jonathan D.
背景/目的：我们对维持性透析患者心脏保护药物有效性的理解是基于在单个时间点评估的药物暴露。我们采用了一种新颖的、与时间相关的方法来模拟药物使用随时间的变化，以检查大型全国队列的结果。方法：我们将医疗补助处方索赔与美国肾脏数据系统注册数据和 52,922 名高血压维持性透析患者的医疗保险索赔联系起来。全因死亡率和合并心血管疾病 (CVD) 终点被建模为心脏保护性抗高血压药物（肾素血管紧张素系统拮抗剂、β-肾上腺素能阻滞剂和钙通道阻滞剂）暴露的函数，通过三个时间依赖性协变量（每周暴露状态、前几周暴露的比例以及暴露状态的转换次数）和倾向调整进行测量。结果：与未暴露相比，当前心脏保护药物暴露状态与较低的调整后死亡率 (AHR) 相关，尽管其幅度取决于前几周用药的比例（持续时间）以及主动和非主动使用之间的切换次数（切换）（AHR 范围 0.54-0.90）。合并 CVD 终点取决于用药周数的比例：10% 周数的 AHR = 1.18，90% 周数 AHR = 0.90。对于转换次数较少的患者，合并 CVD 终点也较低。结论：有效性不仅取决于是否有可用的药物，还取决于使用的持续时间和稳定性，这可能反映了临床稳定性和患者行为的变化。 (C) 2014 S. Karger AG，巴塞尔
Background/Aims: Our understanding of the effectiveness of cardioprotective medications in maintenance dialysis patients is based upon drug exposures assessed at a single point in time. We employed a novel, time-dependent approach to modeling medication use over time to examine outcomes in a large national cohort. Methods: We linked Medicaid prescription claims with United States Renal Data System registry data and Medicare claims for 52,922 hypertensive maintenance dialysis patients. All-cause mortality and a combined cardiovascular disease (CVD)-endpoint were modeled as functions of exposure to cardioprotective antihypertensive medications ( renin angiotensin system antagonists, beta-adrenergic blockers, and calcium channel blockers) measured with three time-dependent covariates ( weekly exposure status, proportion of prior weeks with exposure, and number of switches in exposure status) and with propensity adjustment. Results: Current cardioprotective medication exposure status as compared to not exposed was associated with lower adjusted hazard ratios (AHRs) for mortality, though the magnitude depended upon the proportion of prior weeks with medication (duration) and the number of switches between active and non-active use (switches) (AHR range 0.54-0.90). Combined CVD-endpoints depended upon the proportion of weeks on medication: AHR = 1.18 for 10% and AHR = 0.90 for 90% of weeks. Combined CVD-endpoint was also lower for patients with fewer switches. Conclusions: Effectiveness depends not only on having a drug available but is tempered by duration and stability of use, likely reflecting variation in clinical stability and patient behavior. (C) 2014 S. Karger AG, Basel