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

Abstract

Background There is evidence that angiotensin-converting enzyme inhibitors (ACEI) and angiotensin-II receptor blockers (ARB) may reduce cardiovascular (CV) risk in patients undergoing peritoneal dialysis (PD), but no studies have compared the effectiveness between these drug classes. In this observational cohort study, we compared the association of ARB vs. ACEI use on CV outcomes in patients initiating PD. Methods We identified from the US Renal Data System all adult patients who initiated PD from 2007–2011 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 excluded patients who used both ACEI and ARB. We applied Cox proportional hazards regression to an inverse probability of treatment-weighted cohort to estimate the hazard ratios (HR) for the combined outcome of all-cause death, ischemic stroke, or myocardial infarction; all-cause mortality; and CV death. Results Among 1,892 patients using either drug class, 39% were ARB users. We observed 624 events over 2,898 person-years of follow-up, for a composite event rate of 22 events per 100 person-years. We observed no differences between ARB vs. ACEI users: composite outcome HR: 0.94, 95% confidence interval (CI): 0.79–1.11; all-cause mortality HR: 0.92, 95%CI: 0.76–1.10; CV death HR: 1.06, 95%CI: 0.80–1.41. Conclusion We identified no significant difference in the risks of CV events or death between users of ARBs vs. ACEIs in patients initiating PD, thus supporting their mostly interchangeable use in this population.

Uncertainties in BP management in dialysis patients

“…More recently, in an observational cohort study of 4879 patients initiating PD, the use of ACEi or ARB was associated with a lower risk of fatal CV outcomes (HR 0.74, 95% CI 0.63‐0.87) 161 . No significant differences were demonstrated in all‐cause and CV death in subgroup analysis of 1892 patients when comparing ACEi and ARB therapy 161,162 . Furthermore, pilot randomized trials have suggested that mineralocorticoid receptor antagonist add‐on therapy, in patients on PD, is associated with an improvement in a number of surrogate markers such as LV mass index and ejection fraction, without a rise in the incidence of hyperkalemia 163–165 .…”

The comparison of risk of stroke in patients with peritoneal dialysis and hemodialysis: A systematic review and meta‐analysis

“…It is unclear whether the choice of dialysis modality affects the risk of stroke . Each renal replacement modality causes physiological changes that may affect the risk of stroke in a different way . In addition, two main types of stroke, that is, ischemic or hemorrhagic may be associated with different risk profiles and are heterogeneous in etiology .…”

“…[14][15][16][17][18][19][20][21][22][23][24][25][26][27][28] Each renal replacement modality causes physiological changes that may affect the risk of stroke in a different way. 24,25,[27][28][29][30] In addition, two main types of stroke, that is, ischemic or hemorrhagic may be associated with different risk profiles and are heterogeneous in etiology. 31,32 Although the choice of renal replacement therapy usually depends on many factors, it is still important to assess whether the choice of dialysis modality differs with regard to stroke risk.…”