Risk of intradialytic hypotension among different antihypertensives in haemodialysis patients

Background: Evaluating the impact of antihypertensives on intradialytic hypotension (IDH) risk is crucial, given their frequent use in haemodialysis (HD) patients. This study assessed the comparative safety of various antihypertensives in relation to IDH. Methods: This retrospective cohort study at a tertiary medical centre in Taiwan included adult patients initiating HD from 2016 to 2021. Using electronic health records, we retrieved patient demographics and data covering the first 3 years of HD. We classified antihypertensives as angiotensin-converting enzyme inhibitors (ACEIs)/angiotensin receptor blockers (ARBs), alpha blockers, beta blockers and dihydropyridine calcium channel blockers (DHP-CCBs). We defined IDH as a nadir intradialytic blood pressure decrease to <90/100 mmHg (Nadir 90/100) or a decrease of 40 mmHg (Fall 40). Using a generalized linear mixed model, we analysed odds ratios (ORs) and 95% confidence intervals (CIs) for IDH. Results: This study included 115 patients, covering 39 371 HD sessions over an average follow-up of 27.5 months. We identified 4534 IDH events based on Nadir 90/100, with event rates of 5.0% for ACEIs/ARBs, 3.0% for alpha blockers, 6.7% for beta blockers and 4.0% for DHP-CCBs. For Fall 40, we found 4814 IDH events, with rates of 11.5%, 7.7%, 11.4% and 9.2%, respectively. ACEIs/ARBs and beta blockers did not significantly alter IDH risk. CCBs and alpha blockers significantly reduced IDH risk, with Nadir 90/100-adjusted ORs of 0.65 (95% CI 0.55-0.76) for CCBs and 0.57 (95% CI 0.43-0.74) for alpha blockers, compared with sessions without these medications. For Fall 40, adjusted ORs were 0.73 (95% CI 0.64-0.83) for CCBs and 0.61 (95% CI 0.49-0.74) for alpha blockers. Conclusions: Use of beta blockers and ACEIs/ARBs had a neutral effect on IDH risk, while DHP-CCBs and alpha blockers were associated with lower risks of IDH and might be considered for patients with IDH risk factors. These findings support the safe use of antihypertensives in HD patients, offering valuable guidance for clinical medication adjustments.