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Kidney Week

Abstract: TH-PO670

Impact of Angiotensin Converting Enzyme Inhibitors and Angiotensin II Receptor Blockers on Erythropoiesis-Stimulating Agents in the CKD Population in Singapore

Session Information

  • Anemia and Iron Metabolism
    November 03, 2022 | Location: Exhibit Hall, Orange County Convention Center‚ West Building
    Abstract Time: 10:00 AM - 12:00 PM

Category: Anemia and Iron Metabolism

  • 200 Anemia and Iron Metabolism


  • Quek, Karmen, Changi General Hospital, Singapore, Singapore

The hypothesis that angiotensin converting enzyme inhibitors (ACEi) and angiotensin II receptor blockers (ARB) affect erythropoiesis stimulating agent (ESA) dosing requirement remains controversial. To test this hypothesis in the local population, a retrospective observational cohort study was conducted in a group of chronic kidney disease patients with renal anaemia.


The effect of ACEi and ARBs were evaluated by tracing the ESA dosing requirement and haemoglobin concentration achieved within 6 months of newly initiating an ACEi or ARB. Results from 200 patients were compared between patients receiving ESA alone (control arm, N=100) and patients receiving both ESA and ACEi or ARB (intervention arm, N=100). Patients were further divided into 3 groups: ESA alone (N=100), ESA and ACEi (N=50), ESA and ARB (N=50) for stratified analysis. The outcomes evaluated after a 6-month follow-up include ESA dose, haemoglobin concentration and erythropoietin resistance index (ERI). Multiple linear regression analysis with adjustment was performed to eliminate the influence of confounding factors in the heterogeneous patient groups.


The ACEi studied were enalapril (N=33), lisinopril (N=15) and perindopril (N=2). The ARBs studied were losartan (N=23), irbesartan (N=13), telmisartan (N=12) and valsartan (N=2). The addition of ACEi and ARB did not have an effect on ESA dosing requirement (84.1±50.6 vs 91.1±58.1U/kg/week, P=0.37) and haemoglobin concentration (10.7±1.3 vs 10.6±1.2g/dL, P=0.67) in both direct comparison and multiple linear regression analysis. For the stratified analysis, two parameters in the multiple linear regression model, baseline haemoglobin concentration and ESA dose had an effect on ESA dose (P=0.033 and P=0.001, respectively) and ERI (P<0.001 for both) at the end of the 6-month follow-up period.


The findings of this study suggest that ACE inhibitors and ARBs do not contribute to ESA resistance and may be used as indicated in the local CKD population. Nevertheless, given the wide divide in current opinion, it may be prudent to trial dose reduction or cessation of ACEi or ARB in patients if there is no other clearly definable cause for ESA hyporesponsiveness and if the anticipated benefits exceed the anticipated risks.