Kidney Week

Abstract: FR-OR44

Initiation of ACE Inhibitor and ARBs in Patients with Advanced CKD

Session Information

• Interventions to Reduce CKD Progression
  November 03, 2023 | Location: Room 119, Pennsylvania Convention Center
  Abstract Time: 04:57 PM - 05:06 PM

Category: CKD (Non-Dialysis)

• 2302 CKD (Non-Dialysis): Clinical, Outcomes, and Trials

Authors

• Ku, Elaine, UCSF Medical Center, San Francisco, California, United States

Elaine Ku, MD, FASN

• Inker, Lesley Ann, Tufts Medical Center, Boston, Massachusetts, United States

Lesley Ann Inker,

• Tighiouart, Hocine, Tufts Medical Center, Boston, Massachusetts, United States

Hocine Tighiouart,

• Mcculloch, Charles E., UCSF Medical Center, San Francisco, California, United States

Charles E. Mcculloch,

• Adingwupu, Ogechi M., Tufts Medical Center, Boston, Massachusetts, United States

Ogechi M. Adingwupu,

• Greene, Tom, University of Utah Health, Salt Lake City, Utah, United States

Tom Greene,

• Sarnak, Mark J., Tufts Medical Center, Boston, Massachusetts, United States

Mark J. Sarnak,

Background

The treatment benefit of ACEi/ARB initiation on the risk of kidney failure with replacement therapy (KFRT) and mortality remains unclear in patients with CKD stage 4-5 who were not well-represented in individual trials evaluating the use of these agents.

Methods

We pooled individual-level data from 15 trials that included patients with eGFR<30 mL/min/1.73 m² to examine the effect of ACEi/ARB use on the risk of the onset of KFRT, or secondarily, death using Cox models. We performed pre-specified subgroup analyses and tested for interaction to evaluate the effect of ACEi/ARB inhibitor use by baseline albuminuria (<300 mg/g versus >300 mg/g), eGFR (<20 versus >20 mL/min/1.73 m²), age (<65 versus >65 years), race, and history of diabetes. All analyses were conducted in an intention-to-treat approach.

Results

We included 1752 participants from 15 trials, of whom 611 (35%) required KFRT and 215 (12%) died. Overall, ACEi/ARB use was associated with lower risk of KFRT (HR 0.71 [95% CI 0.60-0.83]) but not death (HR 0.95 [95% CI 0.72-1.24]). However, there was heterogeneity in the effect of the intervention on KFRT by baseline severity of albuminiuria (p_interaction=0.08). ACEi/ARB initiation was associated with lower risk of KFRT in those with severe albuminuria (HR 0.68 [95% CI 0.57-0.80]), but not in those without severe albuminuria (HR 1.05; 95% CI 0.60-1.86). There was no interaction between ACEi/ARB use and baseline eGFR, diabetes, race, or age for KFRT (all p_interaction>0.10). For example, the risk of KFRT in those who started ACEi/ARBs was 0.73 (95% CI 0.57-0.94) in those with baseline eGFR <20 mL/min/1.73 m² and 0.69 (95% CI 0.56-0.85) in those with eGFR >20 mL/min/1.73 m².

Conclusion

Data from this pooled individual-level analysis demonstrated a benefit of ACEi/ARB use in delaying onset of KFRT, but not death in patients with stages 4-5, regardless of the baseline eGFR.

Funding

• NIDDK Support