Should We Continue ACE Inhibitors and ARBs in Patients with Advanced Kidney Disease?

Allan S. Brett, MD, reviewing Bhandari S et al. N Engl J Med 2022 Nov 3

A randomized trial suggests that continuing them is safe in patients who are followed carefully.

Angiotensin-converting–enzyme (ACE) inhibitors and angiotensin-receptor blockers (ARBs) can slow progression of mild-to-moderate chronic kidney disease (CKD). But are they beneficial, harmful, or neutral in patients with advanced CKD? To address this question, U.K. researchers identified 411 adults with estimated glomerular filtration rate (GFR) <30 mL/minute/1.73 m2 who had been receiving ACE inhibitors or ARBs and randomized them to discontinue or continue these drugs. At baseline, median serum creatinine was 3.4 mg/dL and median GFR was 18 mL/minute. Patients on dialysis were excluded.

At median follow-up of 3 years, these outcomes were noted:

• Mean GFR was about 13 mL/minute in both groups; however, the proportion of patients progressing to renal replacement therapy or terminal palliative care was 62% with discontinuation and 56% with continuation; this difference just missed statistical significance (hazard ratio, 1.28; 95% confidence interval, 0.99–1.65).
• Mortality was ≈10% in both groups.
• Proteinuria and blood pressure increased transiently in the discontinuation group, but later, no differences were noted between groups.
• Incidences of myocardial infarction, stroke, and heart failure hospitalizations were similar in the two groups.

COMMENT

Continuing ACE inhibitors or ARBs was not harmful in patients with estimated GFR lower than 30 mL/minute. The big question — not quite resolved here — is whether continuing these drugs confers any benefit: The 6 percentage-point difference in progression to end-stage renal disease, favoring the continuation group, would have been significant in a slightly larger study. In my view, these results support continuing ACE inhibitors and ARBs in patients with advanced CKD unless substantial hyperkalemia or otherwise unexplained sudden deterioration in renal function occurs.

https://www.jwatch.org/na55503/2022/11/10/should-we-continue-ace-inhibitors-and-arbs-patients-with?ijkey=VfBUreTV9