Outcomes with Inpatient Use of Midodrine in Patients on Maintenance Hemodialysis with Heart Failure

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Background: Midodrine, a peripheral vasoconstrictor, is commonly used in kidney failure patients for predialytic and intradialytic hypotension. However, in patients with systolic and/or right heart failure (HF), midodrine is potentially harmful. No known studies examine the safety of midodrine in hospitalized patients with kidney failure and HF. Methods: We queried TriNetX database for inpatients with kidney failure and systolic and/or right HF who had at least an event of hypotension (SBP < 110 mm Hg or MAP < 70 mm Hg). Patients requiring critical care, inotropes or vasopressors were excluded. Cohorts were separated based on midodrine use. Temporality was established between hypotension, midodrine use, and hemodialysis, as shown in figure. Cohorts were matched for relevant comorbidities. Results: In patients receiving midodrine, 6-month mortality risk ratio (RR) was significantly higher than no midodrine use (RR 1.53, 95% CI 1.037 to 2.246). Kaplan Meier survival analysis log-rank test at 6 months revealed a Hazard Ratio of 1.54 (95% CI 1.022 to 2.317). Conclusions: In patients with systolic and/or right HF and kidney failure, hypotension is a limiting factor for decongestion and guideline directed therapy implementation, making midodrine a tool used in real world practice for stabilization. Our exploratory results in noncritically ill inpatients show an association between use of midodrine and higher 6-month mortality. This may reflect deleterious effects from vasoconstriction and/or unmeasured confounders in sicker patients with HF and kidney failure that increase mortality risk. This study has multiple limitations. Given its observational nature, it cannot establish a cause-effect relationship. Other limitations include the lack of data regarding dosage and duration of midodrine, and severity and etiology of heart failure. Our study demonstrates increased mortality associated with midodrine use for hypotension, warranting further research and consideration of alternative strategies.Methods

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