Longer Predialysis ACEi/ARB Utilization Is Associated With Reduced Postdialysis Mortality

Elvira O. Gosmanova, Miklos Z. Molnar, Adnan Naseer, Keiichi Sumida, Praveen Potukuchi, Abduzhappar Gaipov, Barry M. Wall, Fridtjof Thomas, Elani Streja, Kamyar Kalantar-Zadeh, Csaba P. Kovesdy

Research output: Contribution to journalArticle

Abstract

Background: Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers (ACEi/ARB) improve predialysis outcomes; however, ACEi/ARB are underused in patients transitioning to dialysis. We examined the association of different patterns of predialysis ACEi/ARB use with postdialysis survival and whether potentially modifiable adverse events are associated with lower predialysis ACEi/ARB use. Methods: This was a historic cohort study of 34,676 US veterans with, and 10,690 without, ACEi/ARB exposure in the 3-year predialysis period who subsequently transitioned to dialysis between 2007 and 2014. Associations of different patterns of predialysis ACEi/ARB use with postdialysis all-cause mortality and with predialysis acute kidney injury and hyperkalemia events were examined using multivariable adjusted regression analyses. Results: The mean age of the cohort was 70 years, 98% were males and 27% were African Americans. Compared to ACEi/ARB nonuse, continuous ACEi/ARB use was associated with lower postdialysis all-cause mortality (adjusted hazard ratio [aHR]; 95% confidence interval [95% CI] 0.87; 0.83-0.92). In analyses modeling the duration of predialysis ACEi/ARB use, ACEi/ARB use of 50%-74% and ≥75% were associated with lower mortality compared to nonuse (adjusted hazard ratio, 95% confidence interval 0.96, 0.92-0.99 and 0.91; 0.88-0.94, respectively), whereas no increase in postdialysis survival was observed with shorter predialysis ACEi/ARB use. Predialysis acute kidney injury was associated with shorter duration (<50%) of ACEi/ARB use and hyperkalemia was associated with interrupted and ACEi/ARB use of <75%. Conclusions: Longer predialysis ACEi/ARB exposure was associated with lower postdialysis mortality. Prospective studies are needed to evaluate the benefits of strategies enabling uninterrupted predialysis ACEi/ARB use.

Original languageEnglish
JournalAmerican Journal of Medicine
DOIs
Publication statusAccepted/In press - 2020

Keywords

  • Angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (ACEi/ARB)
  • Dialysis
  • End-stage kidney disease (ESKD)
  • Mortality
  • Veterans

ASJC Scopus subject areas

  • Medicine(all)

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  • Cite this

    Gosmanova, E. O., Molnar, M. Z., Naseer, A., Sumida, K., Potukuchi, P., Gaipov, A., Wall, B. M., Thomas, F., Streja, E., Kalantar-Zadeh, K., & Kovesdy, C. P. (Accepted/In press). Longer Predialysis ACEi/ARB Utilization Is Associated With Reduced Postdialysis Mortality. American Journal of Medicine. https://doi.org/10.1016/j.amjmed.2020.03.037