{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,10]],"date-time":"2026-08-10T14:41:51Z","timestamp":1786372911103,"version":"build-2736575974"},"reference-count":49,"publisher":"Ovid Technologies (Wolters Kluwer Health)","issue":"8","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["CJASN"],"published-print":{"date-parts":[[2020,8]]},"abstract":"\n Background and objectives<\/jats:title>\n Elevated BP is an important risk factor for cardiovascular disease, with a prevalence of over 80% in patients undergoing maintenance dialysis. We assessed the comparative BP-lowering efficacy and the safety of BP-lowering drugs in patients undergoing maintenance dialysis.<\/jats:p>\n <\/jats:sec>\n \n Design, settings, participants, & measurements<\/jats:title>\n We performed a frequentist random effects network meta-analysis of randomized, controlled trials evaluating BP-lowering agents in adult patients undergoing maintenance dialysis. Electronic databases (CENTRAL, MEDLINE, and Embase) were systematically searched (up to August 2018) for relevant trials. The main outcome was systolic BP reduction.<\/jats:p>\n <\/jats:sec>\n \n Results<\/jats:title>\n \n Forty trials (4283 participants) met our inclusion criteria. Angiotensin-converting enzyme inhibitors,\n \u03b2<\/jats:italic>\n -blockers, calcium-channel blockers, and aldosterone antagonists lowered systolic BP to a greater extent than placebo, with effect sizes ranging from \u221210.8 mm Hg (95% confidence interval, \u221214.8 to \u22126.7 mm Hg) for the aldosterone antagonists to \u22124.3 mm Hg (95% confidence interval, \u22127.2 to \u22121.5 mm Hg) for angiotensin-converting enzyme inhibitors. Aldosterone antagonists and\n \u03b2<\/jats:italic>\n -blockers were superior to angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, calcium-channel blockers, and renin inhibitors at lowering systolic BP. Compared with angiotensin-converting enzyme inhibitors, aldosterone antagonists and\n \u03b2<\/jats:italic>\n -blockers lowered systolic BP by 6.4 mm Hg (95% confidence interval, \u221211.4 to \u22121.4 mm Hg) and 4.4 mm Hg (95% confidence interval, \u22127.4 to \u22121.3 mm Hg), respectively. Systolic BP reduction was not different with angiotensin receptor blockers,\n \u03b1<\/jats:italic>\n -blockers, and calcium-channel blockers compared with angiotensin-converting enzyme inhibitors. Renin inhibitors were less effective. Angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and aldosterone antagonists incurred risks of drug discontinuation due to adverse events and hypotension.\n <\/jats:p>\n <\/jats:sec>\n \n Conclusions<\/jats:title>\n \n BP-lowering agents significantly reduced systolic BP in patients undergoing maintenance dialysis.\n \u03b2<\/jats:italic>\n -Blockers and aldosterone antagonists may confer larger reductions, although treatment with aldosterone antagonists may be limited by adverse events.\n <\/jats:p>\n <\/jats:sec>","DOI":"10.2215\/cjn.12201019","type":"journal-article","created":{"date-parts":[[2020,7,16]],"date-time":"2020-07-16T15:54:35Z","timestamp":1594914875000},"page":"1129-1138","source":"Crossref","is-referenced-by-count":11,"title":["Comparative Efficacy and Safety of BP-Lowering Pharmacotherapy in Patients Undergoing Maintenance Dialysis"],"prefix":"10.2215","volume":"15","clinical-trial-number":[{"clinical-trial-number":"nct01848639","registry":"10.18810\/clinical-trials-gov"},{"clinical-trial-number":"nct03020303","registry":"10.18810\/clinical-trials-gov"}],"author":[{"given":"Ahmed M.","family":"Shaman","sequence":"first","affiliation":[{"name":"The George Institute for Global Health, Faculty of Medicine, The University of New South Wales, Sydney, New South Wales, Australia"},{"name":"Medication Safety Research Chair, Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1838-3348","authenticated-orcid":false,"given":"Brendan","family":"Smyth","sequence":"additional","affiliation":[{"name":"The George Institute for Global Health, Faculty of Medicine, The University of New South Wales, Sydney, New South Wales, Australia"},{"name":"Sydney School of Public Health, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Clare","family":"Arnott","sequence":"additional","affiliation":[{"name":"The George Institute for Global Health, Faculty of Medicine, The University of New South Wales, Sydney, New South Wales, Australia"},{"name":"Department of Cardiology, The Royal Prince Alfred Hospital, Sydney, New South Wales, Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Suetonia C.","family":"Palmer","sequence":"additional","affiliation":[{"name":"Department of Medicine, University of Otago Christchurch, Christchurch, New Zealand"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Anastasia S.","family":"Mihailidou","sequence":"additional","affiliation":[{"name":"Department of Cardiology and Kolling Institute, Northern Sydney Local Health District, St. Leonards, New South Wales, Australia"},{"name":"Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, New South Wales, Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Meg J.","family":"Jardine","sequence":"additional","affiliation":[{"name":"The George Institute for Global Health, Faculty of Medicine, The University of New South Wales, Sydney, New South Wales, Australia"},{"name":"Department of Renal Medicine, Concord Repatriation General Hospital, Sydney, New South Wales, Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Martin P.","family":"Gallagher","sequence":"additional","affiliation":[{"name":"The George Institute for Global Health, Faculty of Medicine, The University of New South Wales, Sydney, New South Wales, Australia"},{"name":"Concord Clinical School, Sydney Medical School, Faculty of Health and Medicine, University of Sydney, Sydney, New South Wales, Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Vlado","family":"Perkovic","sequence":"additional","affiliation":[{"name":"The George Institute for Global Health, Faculty of Medicine, The University of New South Wales, Sydney, New South Wales, Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Min","family":"Jun","sequence":"additional","affiliation":[{"name":"The George Institute for Global Health, Faculty of Medicine, The University of New South Wales, Sydney, New South Wales, Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"276","published-online":{"date-parts":[[2020,7,16]]},"reference":[{"issue":"Suppl 1","key":"B1-20230813","doi-asserted-by":"crossref","first-page":"A7","DOI":"10.1053\/j.ajkd.2018.01.002","article-title":"US Renal Data System 2017 annual data report: Epidemiology of kidney disease in the United States [published correction appears in Am J Kidney Dis 71: 501, 2018]","volume":"71","author":"Saran","year":"2018","journal-title":"Am J Kidney Dis"},{"key":"B2-20230813","doi-asserted-by":"crossref","first-page":"291","DOI":"10.1016\/S0002-9343(03)00366-8","article-title":"Prevalence, treatment, and control of hypertension in chronic hemodialysis patients in the United States","volume":"115","author":"Agarwal","year":"2003","journal-title":"Am J Med"},{"key":"B3-20230813","doi-asserted-by":"crossref","first-page":"1009","DOI":"10.1016\/S0140-6736(09)60212-9","article-title":"Effect of lowering blood pressure on cardiovascular events and mortality in patients on dialysis: A systematic review and meta-analysis of randomised controlled trials","volume":"373","author":"Heerspink","year":"2009","journal-title":"Lancet"},{"key":"B4-20230813","doi-asserted-by":"crossref","first-page":"860","DOI":"10.1161\/HYPERTENSIONAHA.108.128116","article-title":"Cardiovascular protection with antihypertensive drugs in dialysis patients: Systematic review and meta-analysis","volume":"53","author":"Agarwal","year":"2009","journal-title":"Hypertension"},{"key":"B5-20230813","first-page":"CD004289","article-title":"HMG CoA reductase inhibitors (statins) for dialysis patients","volume":"9","author":"Palmer","year":"2013","journal-title":"Cochrane Database Syst Rev"},{"key":"B6-20230813","doi-asserted-by":"crossref","first-page":"f2914","DOI":"10.1136\/bmj.f2914","article-title":"Demystifying trial networks and network meta-analysis","volume":"346","author":"Mills","year":"2013","journal-title":"BMJ"},{"key":"B7-20230813","doi-asserted-by":"crossref","first-page":"777","DOI":"10.7326\/M14-2385","article-title":"The PRISMA extension statement for reporting of systematic reviews incorporating network meta-analyses of health care interventions: Checklist and explanations","volume":"162","author":"Hutton","year":"2015","journal-title":"Ann Intern Med"},{"key":"B8-20230813","doi-asserted-by":"crossref","first-page":"d5928","DOI":"10.1136\/bmj.d5928","article-title":"The Cochrane Collaboration\u2019s tool for assessing risk of bias in randomised trials","volume":"343","author":"Higgins","year":"2011","journal-title":"BMJ"},{"key":"B9-20230813","doi-asserted-by":"crossref","first-page":"e99682","DOI":"10.1371\/journal.pone.0099682","article-title":"Evaluating the quality of evidence from a network meta-analysis","volume":"9","author":"Salanti","year":"2014","journal-title":"PLoS One"},{"key":"B10-20230813","doi-asserted-by":"crossref","first-page":"177","DOI":"10.1016\/0197-2456(86)90046-2","article-title":"Meta-analysis in clinical trials","volume":"7","author":"DerSimonian","year":"1986","journal-title":"Control Clin Trials"},{"key":"B11-20230813","doi-asserted-by":"crossref","first-page":"80","DOI":"10.1002\/jrsm.1037","article-title":"Indirect and mixed-treatment comparison, network, or multiple-treatments meta-analysis: Many names, many benefits, many concerns for the next generation evidence synthesis tool","volume":"3","author":"Salanti","year":"2012","journal-title":"Res Synth Methods"},{"key":"B12-20230813","doi-asserted-by":"crossref","first-page":"332","DOI":"10.1093\/ije\/dys222","article-title":"Evaluation of inconsistency in networks of interventions","volume":"42","author":"Veroniki","year":"2013","journal-title":"Int J Epidemiol"},{"key":"B13-20230813","doi-asserted-by":"crossref","first-page":"932","DOI":"10.1002\/sim.3767","article-title":"Checking consistency in mixed treatment comparison meta-analysis","volume":"29","author":"Dias","year":"2010","journal-title":"Stat Med"},{"key":"B14-20230813","doi-asserted-by":"crossref","first-page":"140","DOI":"10.1093\/ije\/31.1.140","article-title":"Meta-analyses involving cross-over trials: Methodological issues","volume":"31","author":"Elbourne","year":"2002","journal-title":"Int J Epidemiol"},{"key":"B15-20230813","doi-asserted-by":"crossref","first-page":"557","DOI":"10.1136\/bmj.327.7414.557","article-title":"Measuring inconsistency in meta-analyses","volume":"327","author":"Higgins","year":"2003","journal-title":"BMJ"},{"key":"B16-20230813","doi-asserted-by":"crossref","first-page":"111","DOI":"10.1002\/jrsm.1045","article-title":"Consistency and inconsistency in network meta-analysis: Model estimation using multivariate meta-regression","volume":"3","author":"White","year":"2012","journal-title":"Res Synth Methods"},{"key":"B17-20230813","doi-asserted-by":"crossref","first-page":"52","DOI":"10.1016\/j.jclinepi.2014.08.012","article-title":"Predictive distributions were developed for the extent of heterogeneity in meta-analyses of continuous outcome data","volume":"68","author":"Rhodes","year":"2015","journal-title":"J Clin Epidemiol"},{"key":"B18-20230813","doi-asserted-by":"crossref","first-page":"818","DOI":"10.1093\/ije\/dys041","article-title":"Predicting the extent of heterogeneity in meta-analysis, using empirical data from the Cochrane Database of Systematic Reviews","volume":"41","author":"Turner","year":"2012","journal-title":"Int J Epidemiol"},{"key":"B19-20230813","doi-asserted-by":"crossref","first-page":"161","DOI":"10.1002\/jrsm.57","article-title":"Using network meta-analysis to evaluate the existence of small-study effects in a network of interventions","volume":"3","author":"Chaimani","year":"2012","journal-title":"Res Synth Methods"},{"key":"B20-20230813","doi-asserted-by":"crossref","first-page":"3","DOI":"10.1177\/1536867X0800800102","article-title":"Metan: Fixed-and random-effects meta-analysis","volume":"8","author":"Harris","year":"2008","journal-title":"Stata J"},{"key":"B21-20230813","doi-asserted-by":"crossref","first-page":"951","DOI":"10.1002\/lary.25688","article-title":"Epley and Semont maneuvers for posterior canal benign paroxysmal positional vertigo: A network meta-analysis","volume":"126","author":"Liu","year":"2016","journal-title":"Laryngoscope"},{"key":"B22-20230813","doi-asserted-by":"crossref","first-page":"905","DOI":"10.1177\/1536867X1501500402","article-title":"Visualizing assumptions and results in network meta-analysis: The network graphs package","volume":"15","author":"Chaimani","year":"2015","journal-title":"Stata J"},{"key":"B23-20230813","doi-asserted-by":"crossref","first-page":"105","DOI":"10.1161\/01.CIR.82.1.105","article-title":"Salt and water retention and calcium blockade in uremia","volume":"82","author":"London","year":"1990","journal-title":"Circulation"},{"key":"B24-20230813","doi-asserted-by":"crossref","first-page":"288","DOI":"10.1136\/bmj.280.6210.288","article-title":"Effects of an angiotensin-converting enzyme inhibitor (captopril) on blood pressure in anephric subjects","volume":"280","author":"Man in \u2019t Veld","year":"1980","journal-title":"BMJ"},{"key":"B25-20230813","doi-asserted-by":"crossref","first-page":"1067","DOI":"10.1136\/bmj.280.6221.1067","article-title":"Absence of blood-pressure lowering effect of captopril in anephric patients","volume":"280","author":"Leslie","year":"1980","journal-title":"BMJ"},{"key":"B26-20230813","doi-asserted-by":"crossref","first-page":"e57511","DOI":"10.1371\/journal.pone.0057511","article-title":"Aldosterone and mortality in hemodialysis patients: Role of volume overload","volume":"8","author":"Hung","year":"2013","journal-title":"PLoS One"},{"key":"B27-20230813","doi-asserted-by":"crossref","first-page":"1912","DOI":"10.1056\/NEJM199212313272704","article-title":"Sympathetic overactivity in patients with chronic renal failure","volume":"327","author":"Converse","year":"1992","journal-title":"N Engl J Med"},{"key":"B28-20230813","doi-asserted-by":"crossref","first-page":"166","DOI":"10.1159\/000441262","article-title":"Mineralocorticoid receptor antagonists in end-stage renal disease: Efficacy and safety","volume":"41","author":"Bomback","year":"2016","journal-title":"Blood Purif"},{"key":"B29-20230813","doi-asserted-by":"crossref","first-page":"973","DOI":"10.1016\/j.kint.2018.08.034","article-title":"Safety and cardiovascular efficacy of spironolactone in dialysis-dependent ESRD (SPin-D): A randomized, placebo-controlled, multiple dosage trial","volume":"95","author":"Charytan","year":"2019","journal-title":"Kidney Int"},{"key":"B30-20230813","doi-asserted-by":"crossref","first-page":"983","DOI":"10.1016\/j.kint.2018.11.025","article-title":"A randomized controlled trial of the effect of spironolactone on left ventricular mass in hemodialysis patients","volume":"95","author":"Hammer","year":"2019","journal-title":"Kidney Int"},{"key":"B31-20230813","doi-asserted-by":"crossref","first-page":"219","DOI":"10.1111\/sdi.12691","article-title":"Beta blockers in patients with end-stage renal disease: Evidence-based recommendations","volume":"31","author":"Weir","year":"2018","journal-title":"Semin Dial"},{"key":"B32-20230813","doi-asserted-by":"crossref","first-page":"987","DOI":"10.1681\/ASN.2014040324","article-title":"\u03b2-Blocker dialyzability and mortality in older patients receiving hemodialysis","volume":"26","author":"Weir","year":"2015","journal-title":"J Am Soc Nephrol"},{"key":"B33-20230813","doi-asserted-by":"crossref","first-page":"500","DOI":"10.1161\/HYPERTENSIONAHA.108.125674","article-title":"Dry-weight reduction in hypertensive hemodialysis patients (DRIP): A randomized, controlled trial","volume":"53","author":"Agarwal","year":"2009","journal-title":"Hypertension"},{"key":"B34-20230813","doi-asserted-by":"crossref","first-page":"1080","DOI":"10.1038\/ki.2011.213","article-title":"The effects of frequent nocturnal home hemodialysis: The frequent hemodialysis network nocturnal trial","volume":"80","author":"Rocco","year":"2011","journal-title":"Kidney Int"},{"key":"B35-20230813","doi-asserted-by":"crossref","first-page":"1898","DOI":"10.1681\/ASN.2015111225","article-title":"A trial of extending hemodialysis hours and quality of life","volume":"28","author":"Jardine","year":"2017","journal-title":"J Am Soc Nephrol"},{"key":"B36-20230813","doi-asserted-by":"crossref","first-page":"2287","DOI":"10.1056\/NEJMoa1001593","article-title":"In-center hemodialysis six times per week versus three times per week [published correction appears in N Engl J Med 364: 93, 2011]","volume":"363","author":"Chertow","year":"2010","journal-title":"N Engl J Med"},{"key":"B37-20230813","doi-asserted-by":"crossref","first-page":"1291","DOI":"10.1001\/jama.298.11.1291","article-title":"Effect of frequent nocturnal hemodialysis vs conventional hemodialysis on left ventricular mass and quality of life: A randomized controlled trial","volume":"298","author":"Culleton","year":"2007","journal-title":"JAMA"},{"key":"B38-20230813","doi-asserted-by":"crossref","first-page":"774","DOI":"10.1681\/ASN.2014080831","article-title":"\u03b2-Blockers in dialysis patients: A nephrocardiology perspective","volume":"26","author":"Shroff","year":"2015","journal-title":"J Am Soc Nephrol"},{"key":"B39-20230813","doi-asserted-by":"crossref","first-page":"1152","DOI":"10.1016\/j.jacc.2011.04.041","article-title":"Effects of beta-adrenergic antagonists in patients with chronic kidney disease: A systematic review and meta-analysis","volume":"58","author":"Badve","year":"2011","journal-title":"J Am Coll Cardiol"},{"key":"B40-20230813","doi-asserted-by":"crossref","first-page":"2124","DOI":"10.2215\/CJN.02680314","article-title":"Intradialytic hypotension and risk of cardiovascular disease","volume":"9","author":"Stef\u00e1nsson","year":"2014","journal-title":"Clin J Am Soc Nephrol"},{"key":"B41-20230813","doi-asserted-by":"crossref","first-page":"266","DOI":"10.1053\/j.ajkd.2016.09.015","article-title":"Dialysate potassium, serum potassium, mortality, and arrhythmia events in hemodialysis: Results from the Dialysis Outcomes and Practice Patterns Study (DOPPS)","volume":"69","author":"Karaboyas","year":"2017","journal-title":"Am J Kidney Dis"},{"key":"B42-20230813","doi-asserted-by":"crossref","first-page":"1540","DOI":"10.1016\/S0140-6736(19)32135-X","article-title":"Patiromer versus placebo to enable spironolactone use in patients with resistant hypertension and chronic kidney disease (AMBER): A phase 2, randomised, double-blind, placebo-controlled trial","volume":"394","author":"Agarwal","year":"2019","journal-title":"Lancet"},{"key":"B43-20230813","doi-asserted-by":"crossref","first-page":"672","DOI":"10.1093\/ndt\/gft515","article-title":"Hypertension in hemodialysis patients treated with atenolol or lisinopril: A randomized controlled trial","volume":"29","author":"Agarwal","year":"2014","journal-title":"Nephrol Dial Transplant"},{"key":"B44-20230813","doi-asserted-by":"crossref","first-page":"591","DOI":"10.1053\/j.ajkd.2016.04.011","article-title":"The safety and efficacy of mineralocorticoid receptor antagonists in patients who require dialysis: A systematic review and meta-analysis","volume":"68","author":"Quach","year":"2016","journal-title":"Am J Kidney Dis"},{"key":"B45-20230813","doi-asserted-by":"crossref","first-page":"206","DOI":"10.1186\/s12882-017-0605-7","article-title":"Effects of angiotensin-converting enzyme inhibitors and angiotensin receptor blockers on cardiovascular events and residual renal function in dialysis patients: A meta-analysis of randomised controlled trials","volume":"18","author":"Liu","year":"2017","journal-title":"BMC Nephrol"},{"key":"B46-20230813","doi-asserted-by":"crossref","first-page":"60","DOI":"10.1016\/j.jclinepi.2018.08.022","article-title":"GRADE approach to rate the certainty from a network meta-analysis: Avoiding spurious judgments of imprecision in sparse networks","volume":"105","author":"Brignardello-Petersen","year":"2019","journal-title":"J Clin Epidemiol"},{"key":"B47-20230813","doi-asserted-by":"crossref","first-page":"657","DOI":"10.1097\/HJH.0000000000001283","article-title":"Hypertension in dialysis patients: A consensus document by the European renal and cardiovascular medicine (EURECA-m) working group of the European renal association - European dialysis and transplant association (ERA-EDTA) and the hypertension and the kidney working group of the European society of hypertension (ESH)","volume":"35","author":"Sarafidis","year":"2017","journal-title":"J Hypertens"},{"key":"B48-20230813","doi-asserted-by":"crossref","first-page":"515","DOI":"10.1093\/ndt\/gfy247","article-title":"The association of interdialytic blood pressure variability with cardiovascular events and all-cause mortality in haemodialysis patients","volume":"34","author":"Sarafidis","year":"2019","journal-title":"Nephrol Dial Transplant"},{"key":"B49-20230813","doi-asserted-by":"crossref","first-page":"2062","DOI":"10.2215\/CJN.00870116","article-title":"Pharmacotherapy of hypertension in chronic dialysis patients","volume":"11","author":"Georgianos","year":"2016","journal-title":"Clin J Am Soc Nephrol"}],"container-title":["Clinical Journal of the American Society of Nephrology"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.ovid.com\/10.2215\/CJN.12201019","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,8,10]],"date-time":"2026-08-10T13:39:55Z","timestamp":1786369195000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.ovid.com\/10.2215\/CJN.12201019"}},"subtitle":["A Network Meta-Analysis of Randomized, Controlled Trials"],"short-title":[],"issued":{"date-parts":[[2020,7,16]]},"references-count":49,"journal-issue":{"issue":"8","published-print":{"date-parts":[[2020]]}},"URL":"https:\/\/doi.org\/10.2215\/cjn.12201019","relation":{},"ISSN":["1555-9041","1555-905X"],"issn-type":[{"value":"1555-9041","type":"print"},{"value":"1555-905X","type":"electronic"}],"subject":[],"published":{"date-parts":[[2020,7,16]]}}}