Beta blockers in the management of chronic kidney disease

Abstract

The sympathetic nervous system modulates renal function through its receptors namely β1 (cardiac output and renin release), α1 (systemic and renovascular constriction), and β2 renovascular dilation. Sympathetic overactivity is commonly seen in chronic kidney disease (CKD) and is an important contributor to increasing the risk of cardiovascular events as well as increasing renal disease progression. Recent evaluations of drug use in people with CKD shows a remarkably low percentage of patients receiving β-blockers, especially in more advanced stage CKD when cardiovascular risk is higher. This is in large part due to tolerability of these agents. Moreover, water-soluble β-blockers such as atenolol and metoprolol are dialyzable and require supplementation to avoid exacerbation of arrhythmias following dialysis. Newer vasodilating β-blockers have better tolerability and different effects on renal hemodynamics as well as metabolic variables. These effects are related to the relative α1-blocking effect of agents such as carvedilol and labetolol, with carvedilol having relatively greater α-blocking effects. Few studies evaluate β-blockers on cardiovascular risk in CKD patients. Studies with carvedilol demonstrate attenuated increases in albuminuria as well as reduction in cardiovascular events in CKD patients with hypertension. This paper reviews the animal and clinical trial data that evaluate β-blockers in CKD highlighting the vasodilating β-blockers. It is apparent that greater use of this drug class for blood pressure control would further enhance reduction of risk of heart failure, the most common cause of death in the first year of starting dialysis. © 2006 International Society of Nephrology.