Angiotensin-converting enzyme inhibitors, receptor blockers may benefit patients with CKD
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Key takeaways:
- Patients with advanced chronic kidney disease may benefit from use of angiotensin-converting enzyme inhibitors and angiotensin-receptor blockers.
- Use of these drugs was not linked with reduced mortality risk.
Patients with advanced chronic kidney disease may benefit from angiotensin-converting enzyme inhibitor and angiotensin-receptor blocker use, but the antihypertensive agents may not reduce mortality risk, a retrospective analysis shows.
“There is significant debate over the benefit or risk of [angiotensin-converting enzyme inhibitor] ACEi or [angiotensin-receptor blocker] ARB treatment initiation in patients with advanced CKD, who have been traditionally excluded or underrepresented in trials,” Elaine Ku, MD, MAS, from the departments of medicine and pediatrics in the division of nephrology and the department of epidemiology and biostatistics at the University of California, San Francisco, and colleagues wrote. “In this pooled individual-level analysis of 18 trials that evaluated treatment initiation with ACEis or ARBs [vs.] placebo or other antihypertensive agents, the risk for progression to [kidney failure with renal replacement therapy] KFRT was reduced by 34% in those with advanced CKD.
The researchers reviewed data from the Ovid Medline and the Chronic Kidney Disease Epidemiology Collaboration Clinical Trials Consortium from 1946 through 2023. Patients using either an ACEi or an ARB were matched to controls, which were defined as patients received placebo or antihypertensive drugs other than an ACEi or ARB and with a baseline eGFR below 30 mL/min/1.73 m2.
Primary outcome was KFRT, and the secondary outcome was death before KFRT.
“We focused specifically on kidney end points as the primary outcome because most trials we included were focused on kidney outcomes,” the authors wrote. “However, we also examined all-cause death as a secondary outcome because this is a competing risk for KFRT.
“We hypothesized that ACEi or ARB treatment initiation would be associated with lower risk for KFRT and death,” they wrote.
In the prospective review, 1,739 participants from 18 trials were included. Mean age of participants was 54.9 years and mean eGFR was 22.2 mL/min/1.73 m2. Of the participants, investigators found 624 (35.9%) developed KFRT and 133 (7.6%) died during a median follow-up of 34 months,” the authors wrote.
“Overall, ACEi or ARB treatment initiation led to lower risk for KFRT (adjusted hazard ratio, 0.66 [95% CI, 0.55 to 0.79]) but not death (hazard ratio, 0.86 [CI, 0.58 to 1.28]). There was no statistically significant interaction between ACEi or ARB treatment and age, eGFR, albuminuria, or diabetes (P for interaction > 0.05 for all),” they wrote. “Initiation of ACEi or ARB therapy protects against KFRT, but not death, in people with advanced CKD.”
Ku told Healio that the analysis only focused on CKD stage 4 to 5, and the researchers could not determine if use of ACEi and ARB treatment benefited patients with early-stage CKD. “There have been published guidelines on when to start ACEi/ARBs for patients with earlier stages of CKD. Our study focuses specifically on patients with CKD stage 4-5 and demonstrates a kidney benefit to starting these agents if patients are not already on them,” she said.
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