Longer predialysis ACEi/ARB utilization is associated with reduced postdialysis mortality

Abstract Background Angiotensin converting enzyme inhibitors and angiotensin receptor blockers (ACEi/ARB) improve predialysis outcomes; however, ACEi/ARB are underutilized 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 utilization. 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 2007-2014. Associations of different patterns of predialysis ACEi/ARB utilization 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 utilization, ACEi/ARB use of 50-74 and ≥75% were associated with lower mortality compared to nonuse (aHR, 95% CI 0.96, 0.92-0.99 and 0.91; 0.88-0.94, respectively), while no increase in postdialysis survival was observed with shorter predialysis ACEi/ARB use. Predialysis acute kidney injury was associated with shorter duration ( 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 utilization.