Angiotensin receptor blockers are associated with lower mortality than ACE inhibitors in predialytic stage 5 chronic kidney disease: A nationwide study of therapy with renin-angiotensin system blockade.

Chih-Ching Lin,Szu-Yuan Li,Jia-Sin Liu,Chi-Yu Yang,Der-Cherng Tarng,Wu-Chang Yang,Chih-Cheng Hsu,Shuo-Ming Ou,Yu-Te Wu,Min-Juei Tsai,Tatsuo Shimosawa

doi:10.1371/journal.pone.0189126

Abstract

Dual renin angiotensin system (RAS) blockade using angiotensin-receptor blockers (ARBs) in combination with angiotensin converting enzyme inhibitors (ACEIs) is reported to improve proteinuria in both diabetic and non-diabetic patients. However, its renoprotective effect and safety remain uncertain in patients with advanced chronic kidney disease (CKD). From January 1, 2000 through June 30, 2009, we enrolled 14,117 pre-dialytic stage 5 CKD patients with serum creatinine >6mg/dL and hematocrit <28% under the treatment with erythropoiesis stimulating agents and RAS blockade. We used Cox proportional hazards regression models to estimate the hazard ratios (HRs) against the commencement of long-term dialysis and all-cause mortality for ACEI/ARB users. Over a median follow-up of 7 months, 9,867 patients (69.9%) required long-term dialysis and 2,805 (19.9%) died before progression to end-stage renal disease requiring dialysis. In comparison with the ARB-only users, dual blockade with ACEIs and ARBs was associated with a significantly higher risk of (1) death in all CKD patients (HR = 1.49, [95%CI, 1.30–1.71]; P = 0.02) and in diabetic subgroup (HR = 1.58, [95%CI, 1.34–1.86]; P = 0.02); (2) composite endpoint of long-term dialysis or death in diabetic subgroup (HR = 1.10, [95%CI, 1.01–1.20]; P = 0.04); (3) hyperkalemia-associated hospitalization in non-diabetic subgroup (HR, 2.74, [95%CI, 1.05–7.15]; P = 0.04). However, ACEIs users were associated with higher mortality than ARBs users in all CKD patients (HR = 1.17, [95%CI, 1.07–1.27]; P = 0.03) and in diabetic subgroup (HR = 1.32, [95%CI, 1.18–1.48]; P = 0.03). Monotherapy of RAS blockade, especially ARB, is more effective and safer than dual RAS blockade in pre-dialytic stage 5 CKD patients.

Highlights

Angiotensin-converting enzyme inhibitor (ACEI) or angiotensin II receptor blocker (ARB) has been prescribed worldwide to improve proteinuria and delay the progression of chronic kidney disease (CKD) in both diabetic and non-diabetic patients
To explore whether ACEI/ARB therapy is the same effective to those patients with advanced CKD at the pre-dialytic stage, our task group developed a national-wide retrospective study by including all CKD patients diagnosed between January 1, 2000 and June 30, 2009 in Taiwan, who had serum creatinine level >6 mg/ dl and hematocrit level
To bridge the gap in the transition from CKD to ESRD, we assessed the association of the choice of treatment with the risk of long-term dialysis and/or death in this nationwide, large cohort of patients with pre-dialytic stage-5 CKD who had hypertension and anemia, and were treated with ESAs

Summary

Introduction

Angiotensin-converting enzyme inhibitor (ACEI) or angiotensin II receptor blocker (ARB) has been prescribed worldwide to improve proteinuria and delay the progression of chronic kidney disease (CKD) in both diabetic and non-diabetic patients. Previous investigations have disclosed that dual renin angiotensin system (RAS) blockade (combination therapy with an ACEI and an ARB) is more effective in proteinuria reduction, which may provide additional cardiovascular or renoprotective benefit, than either drug alone in renal disease.[5] in the Ongoing Telmisartan Alone and in Combination with Ramipril Global Endpoint Trial (ONTARGET), the authors found that combination therapy with an ACEI and an ARB, compared with monotherapy, did not provide more cardiovascular or renal benefits but increased risk of hyperkalemia and acute kidney injury in persons running an increased cardiovascular risk.[6] Another recent meta-analysis for patients with early CKD (stage 1–3) showed no significant difference, either, between dual ACEI plus ARB combination therapy and monotherapy in reducing mortality risk or delay ESRD development.[7] investigation focusing on the safety and effectiveness of dual RAS blockade in advanced CKD patients, especially at pre-dialytic stage, is lacking. To bridge the gap in the transition from CKD to ESRD, we assessed the association of the choice of treatment (dual RAS blockade vs monotherapy) with the risk of long-term dialysis and/or death in this nationwide, large cohort of patients with pre-dialytic stage-5 CKD who had hypertension and anemia, and were treated with ESAs

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