End-stage renal disease (ESRD) patients starting peritoneal dialysis (PD) may be less likely to experience fatal cardiovascular events when they take angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers, according to a new study.

Jenny I. Shen, MD, and colleagues of Stanford University School of Medicine in Palo Alto, California, identified 4879 low-income Medicare recipients from the US Renal Data System (including seniors and younger adults receiving disability benefits) who started PD between 2007 and 2011. Of these, 2063 (42%) filled a prescription for ACEIs or ARBs via Medicare Part D in the first 90 days of dialysis initiation.

According to results published in Nephrology Dialysis Transplantation, 25 cardiovascular (CV) events per 100 persons per year occurred over a median 1.2 years of follow-up. Compared with patients not taking angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs), users showed a 16% lower risk for the composite outcome of death, myocardial infarction, and stroke. Individually, the risk for all-cause mortality was lower by 17% and CV death by 26%, whereas the risks for myocardial infarction and ischemic stroke, either fatal or non-fatal, were not reduced. The investigators accounted for age, sex, race, diabetes, coronary artery disease, heart failure, and diuretic use.

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Mortality is high in the first year after dialysis initiation, and roughly half of deaths are attributed to CV causes, according to background information in the report. Better CV outcomes as well as survival have been attributed to residual renal function, and ARBs and ACEIs are believed to preserve residual renal function. Yet, when Dr Shen and colleagues performed sensitivity analyses, they found no effect by residual renal function.

“While randomized clinical trials are needed to test whether this is a causal relationship, these findings indicate doctors should consider using or re-starting ACEIs and ARBs as first-line blood pressure medications for patients undergoing peritoneal dialysis,” Dr Shen told Renal & Urology News. “These medications are often stopped when patients are in the late, but pre-dialysis, stages of kidney disease because of the risk of dangerously high potassium levels. The risk of higher potassium levels is minimized after patients have transitioned to peritoneal dialysis, but doctors often don’t resume the medication even though it can usually be re-started safely.”

The investigators were unable to analyze the potential effects of blood pressure as well as physician experience and encourage future research.

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1. Shen JI, Saxena AB, Montez-Rath ME, Chang TI, and Winkelmayer WC. Angiotensin-converting enzyme inhibitor/angiotensin receptor blocker use and cardiovascular outcomes in patients initiating peritoneal dialysis. Nephrol Dial Transplant. 2016 April 13. doi:10.1093/ndt/gfw053. [Epub ahead of print].

2. Blood pressure medications reduce stroke and heart attack in peritoneal dialysis patients. Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center [news release]. June 14, 2016.