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Kidney Week

Abstract: TH-OR057

ACEi/ARB Discontinuation and Adverse Outcomes in CKD

Session Information

Category: CKD (Non-Dialysis)

  • 2102 CKD (Non-Dialysis): Clinical, Outcomes, and Trials

Authors

  • Walther, Carl P., Baylor College of Medicine, Houston, Texas, United States
  • Richardson, Peter, Baylor College of Medicine, Houston, Texas, United States
  • Winkelmayer, Wolfgang C., Baylor College of Medicine, Houston, Texas, United States
  • Ramanathan, Venkat, Baylor College of Medicine, Houston, Texas, United States
  • Virani, Salim S., Baylor College of Medicine, Houston, Texas, United States
  • Navaneethan, Sankar D., Baylor College of Medicine, Houston, Texas, United States
Background

Treatment with ACEi/ARB is standard of care for CKD with albuminuria as it can slow disease progression. However, ACEi/ARB treatment can increase risk of hyperkalemia, hypotension, and acute kidney injury, especially in the setting of intercurrent illnesses. We investigated the association of ACEi/ARB discontinuation with patient characteristics and outcomes among VA patients with non-dialysis dependent CKD.

Methods

Patients followed at the VA who had eGFR<60ml/min/1.73 for >90 days, 2005-13, were identified; those with CKD G5 or ESKD were excluded. Patients entered the cohort at time of incident ACEi/ARB use, 2005-13; discontinuation (based on pharmacy fill data) was treated as a time-varying risk factor. Different durations of discontinuation (<90,90-180,>180 days) were investigated, and death and incident dialysis were the outcomes. We used Cox regression, adjusting for demographic and clinical factors.

Results

We identified 238,615 people who met the inclusion criteria; 96.7% were male, and mean age was 71±10 years. 69,544 deaths and 6,100 dialysis initiations were observed. ACEi/ARB discontinuation was associated with more than doubling the risk of subsequent mortality, with a <90 day discontinuation having a hazard ratio for mortality (compared to no discontinuation) of 2.74 (95%CI 2.67-2.81) on adjusted analysis. Longer discontinuation intervals were also associated more than doubling of mortality risk (Table). ACEi/ARB discontinuation was also associated with more than two-fold increased risk for incident dialysis, with a <90 day discontinuation having a hazard ratio of 2.36 (95%CI 2.17-2.56) on adjusted analysis, and longer durations having similar risk.

Conclusion

ACEi/ARB discontinuation was associated with increased subsequent risk of death and incident dialysis in an elderly male VA cohort. Additional investigation, including causes of discontinuation and outcome circumstances, will elucidate relative contributions of ACEi/ARB discontinuation as a cause of the poor outcomes or a marker of worsening health.