1973

PRESCRIBING PATTERNS OF CARDIOPROTECTIVE MEDICATIONS IN CHRONIC KIDNEY DISEASEAND END STAGE KIDNEY DISEASE

Chiu D, Abeygunarathne T, Ritchie J, Alderson H, SinhaS, Kalra PA, Green D

Institute of Population Health, The University of Manchester, UK

INTRODUCTION: Cardiovascular disease is a major cause of death in patients with chronic kidney disease (CKD). However, few clinical trials exist that specifically address cardioprotective prescribing in CKD or dialysis. We hypothesised that these medications would be under-prescribed in these patients, especially dialysis patients for whom the evidence base is particularly poor.

METHODS: A prospectively collected cross-sectional study of cardioprotectivemedications prescribed to adult CKD patients at the time of first review in a tertiary nephrology outpatient clinic, and in a prevalent cohort of stable chronic haemodialysis patients. Data were collected via patient history and electronic patient records to determinethe proportion of patients prescribed these medications (anti-platelet therapy, lipid-lowering therapy, beta-blockade, renin angiotensin system [RAAS] blockade) in clinical settings where they are specifically indicated (heart failure, coronary artery disease, stroke). CKD and haemodialysis patients were compared using Chi Squared Test.

RESULTS: There were 2093 pre-dialysis patients and of which 876 were included based on having at least one of the co-morbid conditions listed, 67% were male, mean age 70.1±10.6years and 42% had diabetes mellitus. There were 174 haemodialysis patient and 69 patients had one or more of the aforementionedco-morbid factors, 77% were male, mean age 67.5±10.6years and 49% had diabetes mellitus. Beta-blockers were more likely to be prescribed in dialysis than CKD, whereas RAAS blockade was more common in CKD. Lipid-lowering therapy was prescribed in 78% of cases overall and no differences were shown between groups. The findings are detailed in table 1. Table 1.Comparing the use of medication in CKD and haemodialysis. Significant differences between the groups are highlighted. Key: LLT = lipid lowering therapy.

Heart Failure / Coronary Artery Disease / Cerebrovascular Accident
CKD / HD / Sig. / CKD / HD / Sig. / CKD / HD / Sig.
Number of patients / 360 / 29 / - / 621 / 39 / - / 149 / 13 / -
Antiplatelet (%) / 61 / 76 / 0.16 / 76 / 69 / 0.33 / 76 / 62 / 0.32
LLT (%) / 69 / 76 / 0.53 / 78 / 79 / 1.00 / 79 / 85 / 1.00
Beta-blocker (%) / 33 / 77 / 0.01 / 44 / 72 / 0.01 / 32 / 46 / 0.36
RAAS blockade (%) / 66 / 38 / 0.01 / 59 / 56 / 0.87 / 64 / 31 / 0.03
None of above (%) / 5 / 3 / 1.00 / 3 / 0 / 0.63 / 2 / 0 / 1.00

CONCLUSION:Lipid-lowering therapy is widely prescribed in CKD and end stage kidney disease (ESKD), with no statistical difference between them but a numerical trend to higher numbers in dialysis patients. There appears to be scope for further improvement in prescribing but the reasons for non-prescribing are not detailed. This we acknowledge as a shortcoming of the study.

The limited use of beta-blockade in CKD is surprising and warrants further investigation. The better prescribing practice in ESKD for this and lipid lowering therapy may reflect that haemodialysis patients are reviewed more frequently by way of being seen on a dialysis unit. Alternatively,because the cardiovascular risk is known to be greater in ESKD than CKD, more urgency is applied to prescribing for these patients.

The lower rate of RAAS blockade use in ESKD is likely to be due to concerns over worsening renal function and hyperkalaemia. The risk versus benefit in this setting is also in need of further investigation.