Renoprotective Effect of Renin-Angiotensin-Aldosterone System Blockade in Patients With Predialysis Advanced Chronic Kidney Disease, Hypertension, and Anemia

Study Questions:

How effective and safe is angiotensin-converting enzyme inhibitor (ACEI) or angiotensin-receptor blocker (ARB) use for advanced predialysis chronic kidney disease (CKD) in patients with hypertension and anemia?


This was a prospective cohort study in Taiwan. From January 1, 2000, through June 30, 2009, the investigators selected 28,497 hypertensive adult patients with CKD. Serum creatinine levels were >6 mg/dl, hematocrit levels were <28%, and patients were treated with erythropoiesis-stimulating agents. There were users (n = 14,117) and nonusers (n = 14,380) of ACEIs/ARBs. The authors used Cox proportional hazards regression models to estimate hazard ratios (HRs) for commencement of long-term dialysis and all-cause mortality for ACEI/ARB users versus nonusers.


In a median follow-up of 7 months, 20,152 patients (70.7%) required long-term dialysis and 5,696 (20.0%) died before progression to end-stage renal disease requiring dialysis. Use of ACEIs/ARBs was associated with a lower risk for long-term dialysis (HR, 0.94; 95% confidence interval [CI], 0.91-0.97) and the composite outcome of long-term dialysis or death (HR, 0.94; 95% CI, 0.92-0.97). The renal benefit of ACEI/ARB use was consistent across most patient subgroups, as was that of ACEI or ARB monotherapy. Compared with nonusers, the ACEI/ARB users had a higher hyperkalemia-associated hospitalization rate, but the risk of predialysis mortality caused by hyperkalemia was not significantly increased (HR, 1.03; 95% CI, 0.92-1.16; p = 0.30).


The authors concluded that patients with stable hypertension and advanced CKD who receive therapy with ACEIs/ARBs exhibit an association with lower risk for long-term dialysis or death by 6%.


This study reports that ACEI/ARB use reduced the risk of initiation of dialysis and the composite outcome of dialysis or death by 6% among patients with hypertension and predialysis stage 5 CKD. Based on the study findings, every year, ACEI/ARB use could prevent 5.5% of the patients with advanced CKD from commencing long-term dialysis. This study extends the effectiveness of ACEI/ARB use in patients with stages 1-4 CKD to those with stage 5 CKD. It should be noted that this study does not support concomitant use of ACEI and ARB in predialysis stage 5 CKD.

Clinical Topics: Prevention, Hypertension

Keywords: Kidney Failure, Chronic, Taiwan, Hypertension

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