Nephrology Section, Stratton VA Medical Center, Albany, New York; Division of Nephrology, Department of Medicine, Albany Medical College, Albany, New York.
Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee; Division of Transplantation, Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee; Methodist University Hospital Transplant Institute, Memphis, Tennessee.
Am J Med. 2020 Sep;133(9):1065-1073.e3. doi: 10.1016/j.amjmed.2020.03.037. Epub 2020 Apr 21.
Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers (ACEi/ARB) improve predialysis outcomes; however, ACEi/ARB are underused 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 use.
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 and 2014. Associations of different patterns of predialysis ACEi/ARB use with postdialysis all-cause mortality and with predialysis acute kidney injury and hyperkalemia events were examined using multivariable adjusted regression analyses.
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 use, ACEi/ARB use of 50%-74% and ≥75% were associated with lower mortality compared to nonuse (adjusted hazard ratio, 95% confidence interval 0.96, 0.92-0.99 and 0.91; 0.88-0.94, respectively), whereas no increase in postdialysis survival was observed with shorter predialysis ACEi/ARB use. Predialysis acute kidney injury was associated with shorter duration (<50%) of ACEi/ARB use and hyperkalemia was associated with interrupted and ACEi/ARB use of <75%.
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 use.
血管紧张素转换酶抑制剂和血管紧张素受体阻滞剂（ACEi/ARB）可改善透析前患者的预后；然而，在向透析过渡的患者中，ACEi/ARB 的使用不足。我们研究了不同模式的透析前 ACEi/ARB 使用与透析后生存的关系，以及是否潜在可改变的不良事件与透析前 ACEi/ARB 使用不足有关。
这是一项回顾性队列研究，纳入了 2007 年至 2014 年间在美国接受透析治疗的 34676 名 ACEi/ARB 暴露和 10690 名无 ACEi/ARB 暴露的退伍军人，这些患者在透析前 3 年内均有 ACEi/ARB 暴露。使用多变量调整回归分析研究了不同模式的透析前 ACEi/ARB 使用与透析后全因死亡率以及透析前急性肾损伤和高钾血症事件的关系。
队列的平均年龄为 70 岁，98%为男性，27%为非裔美国人。与 ACEi/ARB 不使用者相比，持续使用 ACEi/ARB 与透析后全因死亡率降低相关（调整后的危险比[HR]；95%置信区间[95%CI]0.87；0.83-0.92）。在模拟透析前 ACEi/ARB 使用时间的分析中，ACEi/ARB 使用 50%-74%和≥75%与不使用者相比，死亡率降低（调整后的 HR，95%CI 为 0.96，0.92-0.99 和 0.91；0.88-0.94），而透析前 ACEi/ARB 使用时间较短并未观察到生存率的提高。透析前急性肾损伤与 ACEi/ARB 使用时间较短（<50%）有关，高钾血症与 ACEi/ARB 中断和使用时间<75%有关。
更长时间的透析前 ACEi/ARB 暴露与透析后死亡率降低相关。需要前瞻性研究来评估使透析前 ACEi/ARB 使用不间断的策略的益处。
