Trends in Angiotensin-Converting Enzyme Inhibitor and Angiotensin II Receptor Blocker Use among Those with Impaired Kidney Function in the United States

Significance Statement Although angiotensin-converting enzyme (ACE) inhibitor and angiotensin II receptor blocker (ARB) medications are mainstays of treatment in CKD, the frequency of ACE/ARB use has not been well characterized in this population. Nationally representative data from 1999 to 2014 showed that overall ACE/ARB use during this period was only 34.9% among those with CKD; use rose significantly with time (from 25.5% in 1999–2002 to 40.1% in 2011–2014) but seemed to level off after the early 2000s, a trend similarly observed in multiple CKD subgroups. Overall, regardless of era, ACE/ARB use in CKD was the exception unless concomitant illnesses, like diabetes mellitus or cardiac disease, were present. This suggests that a significant opportunity exists for improvement in the care in community-based CKD. Background Although hypertension is common in CKD and evidence-based treatment of hypertension has changed considerably, contemporary and nationally representative information about use of angiotensin-converting enzyme (ACEs) inhibitors or angiotensin II receptor blockers (ARBs) in CKD is lacking. Methods We examined ACE/ARB trends from 1999 to 2014 among 38,885 adult National Health and Nutrition Examination Survey participants with creatinine-based eGFR<60 ml/min per 1.73 m 2 or urinary albumin-to-creatinine ratio ≥30 mg/g. Results Of 7085 participants with CKD, 34.9% used an ACE/ARB. Across four eras studied, rates of use rose significantly (rates were 25.5% in 1999–2002, 33.3% in 2003–2006, 39.0% in 2007–2010, and 40.1% in 2011–2014) but appeared to plateau after 2003. Among those with CKD, use was significantly greater among non-Hispanic white and black individuals (36.1% and 38.2%, respectively) and lower among Hispanic individuals (26.7%) and other races/ethnicities (29.3%). In age-, sex-, and race/ethnicity-adjusted models, ACE/ARB use was significantly associated with era (adjusted odds ratios aOR, 1.41; 95% confidence interval 95% CI, 1.14 to 1.74 for 2003–2006, 1.84; 95% CI, 1.48 to 2.28 for 2007–2010, and 2.02; 95% CI, 1.61 to 2.53 for 2011–2014 versus 1999–2002); it also was significantly associated with non-Hispanic black versus non-Hispanic white race/ethnicity (aOR, 1.40; 95% CI, 1.19 to 1.66). Other multivariate associations included older age, men, elevated BMI, diabetes mellitus, treated hypertension, cardiac failure, myocardial infarction, health insurance, and receiving medical care within the prior year. Conclusions Rates of ACE/ARB use increased in the early 2000s among United States adults with CKD, but for unclear reasons, use appeared to plateau in the ensuing decade. Research examining barriers to care and other factors is needed.