Patients with stable hypertension and the most advanced stage of chronic kidney disease (CKD) before dialysis appeared to have a lower risk for long-term dialysis or death if they were treated with the antihypertensive drugs known as angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs), according to a study published by JAMA Internal Medicine.
An ACEI or ARB is known to delay the progression of CKD in patients with and without diabetes, particularly in those patients with mild to moderate renal insufficiency. But most large clinical trials of ACEI/ARB exclude patients with the most advanced stage of CKD predialysis, perhaps out of concern that the drugs can cause renal failure and the need for dialysis, so it remains unclear whether that therapy is effective in patients with advanced CKD, according to the study background.
Researchers in Taiwan examined the association between ACEI/ARB use and the risk of long-term dialysis and death in a nationwide group of 28,497 patients in a study by Ta-Wei Hsu, M.D., of the National Yang-Ming University Hospital, and colleagues. The patients had the most advanced predialysis stage of CKD, hypertension and anemia.
During a median follow-up of seven months, 20,152 patients (70.7 percent) required long-term dialysis and 5,696 (20 percent) died before progressing to ESRD (end-stage renal disease). Study findings indicate that treatment with ACEIs/ARBs in patients with stable hypertension and advanced CKD was associated with a lower risk for long-term dialysis or death by 6 percent.
"In conclusion, our findings expand the existing knowledge in the field and provide clinicians with new information," the authors conclude.
In a related commentary, Meyeon Park, M.D., M.A.S., and Chi-yuan Hsu, M.D., M.Sc., of the University of California, San Francisco, write: "In the treatment of patients with advanced chronic kidney disease (CKD) … a paramount goal is preventing or retarding progression to end-stage renal disease and the requirement of dialysis."
"However, the use of ACEIs or ARBs in advanced CKD remains uncertain. This important clinical question is the subject of a new study by Hsu and colleagues," the authors continue. "Overall, the study by Hsu and colleagues makes an important contribution to the literature."
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JAMA Intern Med. Published online December 16, 2013. DOI: 10.1001/jamainternmed.2013.12700
JAMA Intern Med. Published online December 16, 2013. DOI: 10.1001/jamainternmed.2013.12176