ARBs and ACE Inhibitors may prevent kidney failure in CKD patients on dialysis, States study

A new study published in Annals of Internal Medicine found that in patients with advanced chronic kidney disease (CKD), starting angiotensin-converting enzyme inhibitor (ACEi) or angiotensin-receptor blocker (ARB) medication prevents kidney failure with replacement therapy (KFRT) but does not prevent mortality.

The impact of starting an ACEi or an ARB on the likelihood of renal failure with replacement therapy and mortality is yet unknown in individuals with severe CKD. Thereby, Elaine Ku and colleagues carried out this investigation to look at the relationship between rates of KFRT and mortality and the commencement of ACEi or ARB medication compared to a non-ACEi or ARB comparator.

The data for this study were gathered from Ovid Medline and the Chronic Kidney Disease Epidemiology Collaboration Clinical Trials Consortium from 1946 to December 31, 2023. The finalized RCTs compared an ACE inhibitor or an ARB to a comparator (placebo or other antihypertensive medications) that included individuals whose baseline estimated glomerular filtration rate (eGFR) was less than 30 mL/min/1.73 m2.

KFRT was the main outcome, while death prior to KFRT was the secondary outcome. Cox proportional hazards models were employed for analyses in accordance with the intention-to-treat principle. Baseline age (<65 vs. ≥65 years), albuminuria (urine albumin–creatinine ratio <300 vs. ≥300 mg/g), eGFR (<20 vs. ≥20 mL/min/1.73 m2), and history of diabetes were used to perform prespecified subgroup analyses.

Of the total 1739 people from 18 trials, there were 624 (35.9%) who developed KFRT and 133 (7.6%) who passed away during a typical follow-up period of 34 months (IQR, 19 to 40 months), with a mean eGFR of 22.2 mL/min/1.73 m2. Reduction in the risk for KFRT but not the mortality was the overall result of starting ACEi or ARB medication. Age, albuminuria, eGFR or diabetes did not significantly interact with ACEi or ARB therapy (P for interaction > 0.05 for all).

Overall, when ACEi or ARB medication is started in patients with poor GFR, patients can still benefit significantly, even in a time when alternative medicines, including sodium-glucose cotransporter-2 inhibitors, are readily available.

Source:

Ku, E., Inker, L. A., Tighiouart, H., McCulloch, C. E., Adingwupu, O. M., Greene, T., Estacio, R. O., Woodward, M., de Zeeuw, D., Lewis, J. B., Hannedouche, T., Jafar, T. H., Imai, E., Remuzzi, G., Heerspink, H. J. L., Hou, F. F., Toto, R. D., Li, P. K., & Sarnak, M. J. (2024). Angiotensin-Converting Enzyme Inhibitors or Angiotensin-Receptor Blockers for Advanced Chronic Kidney Disease. In Annals of Internal Medicine. American College of Physicians. https://doi.org/10.7326/m23-3236