Angiotensin-converting enzyme inhibitor/angiotensin receptor blocker use and cardiovascular outcomes in patients initiating peritoneal dialysis

Abstract

A B S T R A C TBackground: Data on the effectiveness of angiotensinconverting enzyme inhibitors (ACEIs) and angiotensin II receptor blockers (ARBs) in reducing cardiovascular (CV) risk in patients undergoing peritoneal dialysis (PD) are limited. We investigated the association between ACEI/ARB use and CV outcomes in patients initiating PD. Methods: In this observational cohort study, we identified from the United States Renal Data System all adult patients who initiated PD from 2007 to 2011 and participated in Medicare Part D, a federal prescription drug benefits program, for the first 90 days of dialysis. Patients who filled a prescription for an ACEI or ARB in those 90 days were considered users. We applied Cox regression to an inverse probability of treatment weighted cohort to estimate the hazard ratios (HRs) for the combined outcome of death, ischemic stroke or myocardial infarction (MI) and each outcome individually. Results: Among 4879 patients, 2063 (42%) used an ACEI/ARB. Patients were followed up for a median of 1.2 years. We recorded 1771 events, for a composite rate of 25 events per 100 person-years. ACEI/ARB use (versus nonuse) was associated with a reduced risk of the composite outcome {HR 0.84 [95% confidence interval (CI) 0.76-0.93]}, all-cause mortality ] and CV death ], but not MI )] or ischemic stroke [HR 1.06 (95% CI 0.79-1.43)]. Results were similar in astreated analyses. In a subgroup analysis, we did not find any effect modification by residual renal function. Conclusions: ACEI/ARB use is common in patients initiating PD and is associated with a lower risk of fatal CV outcomes.

Comparative effectiveness of angiotensin receptor blockers vs. angiotensin-converting enzyme inhibitors on cardiovascular outcomes in patients initiating peritoneal dialysis

“…ACEI. Previous studies have shown an association between ACEI or ARB ( vs. no use) and a reduction in CV events in patients on PD,[5,21] but, to our knowledge, ours is the first to compare the two classes of medications in PD patients.…”

“…[1] While angiotensin-converting enzyme inhibitors (ACEI) and angiotensin-II receptor blockers (ARB) are recommended for the reduction of CV events for certain populations without ESKD, there is evidence that these agents may reduce the risk of CV events in patients on maintenance dialysis as well. [2–9] In fact, guidelines recommend the use of either ACEI or ARB as a first-line anti-hypertensive for those with diabetic nephropathy with proteinuria and for patients on dialysis with residual kidney function, and suggest use of either ACEI or ARB for normotensive patients on peritoneal dialysis (PD) with residual kidney function. [10,11]…”

Current guidelines in peritoneal dialysis – Part II

“…The use of angiotensin converting enzyme inhibitors (ACEI), angiotensin II receptor blockers (ARB) and beta blockers (BB) should be considered in PD patients with LVH, dilated cardiomyopathy or systolic heart failure; when already receiving treatment with ACEI or ARB, consider adding a mineralocorticoid receptor antagonist (MRA) 114 . Observational studies showed that ACEI/ARB utilization is associated with a reduction in cardiovascular events, and cardiovascular and all-cause mortality, even after adjusting for other risk factors and patient characteristics 127,128 . Concerning the treatment with MRA, a randomized controlled trial (RCT) in PD showed that, when added to a ACEI or ARB, spironolactone significantly reduces the rate of progression in left ventricular mass index and improves ejection fraction for 24 months 129 .…”

Assessment of the effect of angiotensin-converting enzyme inhibitors and angiotensin receptor blockers in peritoneal dialysis patients: a systematic review and meta-analysis on clinical trials

“…In view of these facts, the clinical question arose as to whether RASIs preserve the RRF of PD patients. Several clinical studies were performed to estimate the effect of RASIs on RRF of PD patients [10][11][12][13][14][15][16][17][18][19][20][21][22], including both randomized controlled trials (RCTs) and non-RCTs, with conflicting results.…”