ACEIs/ARBs Show Renoprotective Effect in Stage 5 CKD Linked to Increased Cancer Risk

In patients with advanced predialysis chronic kidney disease (CKD) and stable hypertension, treatment with a renin-angiotensin-aldosterone system blocker reduces the risk of long-term dialysis or death, reports a study in JAMA Internal Medicine.

The prospective cohort study included 28,497 hypertensive adults in Taiwan with predialysis stage 5 CKD. Eligible patients had serum creatinine greater than 6 mg/dL and hematocrit less than 28 percent, and they were being treated with erythropoiesis-stimulating agents. Of those, 14,117 patients were receiving an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker (ACEI/ARB); the remaining 14,380 patients were not. The rates of long-term dialysis and all-cause mortality were compared by the use of Cox proportional hazards regression models.

At a median follow-up time of 7 months, 70.7 percent of patients had started long-term dialysis, and 20.0 percent had died before progressing to ESRD. Patients receiving ACEIs/ARBs had a small but significant reduction in the risk of long-term dialysis: hazard ratio 0.94. There was a similar reduction in a composite outcome of long-term dialysis and death.

The renoprotective effect of ACEI/ARB use was apparent in most patient subgroups; benefits were also observed with ACEI or ARB treatment. The risk of hospital admission for hyperkalemia was higher among ACEI/ARB users. However, there was no increase in predialysis mortality caused by hyperkalemia.

There are few data on the benefits of ACEI/ARB therapy in patients with stage 5 CKD. In Taiwan, the prevalence and incidence of ESRD are very high, and dialysis is typically started late.

The new data suggest that ACEI/ARB therapy has renal benefits for patients with advanced predialysis CKD. The risk of long-term dialysis or death is reduced by about 6 percent, with no increase in all-cause mortality. The researchers write, “We estimate that, every year, ACEI/ARB use could prevent 5.5 percent of the patients with advanced CKD from commencing long-term dialysis” [Hsu T-W, et al. Renoprotective effect of renin-angiotensin-aldosterone system blockade in patients with predialysis advanced chronic kidney disease, hypertension, and anemia. JAMA Intern Med 2013 Dec 16. doi: 10.1001/jamainternmed.2013.12700].