Synapse
⌘+K
Synapse
PulseExploreJournal ClubResearchersJournals
Instagram
HomeJournal ClubExplore
June 19, 2026Frontiers in PharmacologyOpen Access

Comparative cardiovascular outcomes of renin–angiotensin system inhibitors in patients receiving maintenance hemodialysis: a large real-world cohort study

View Full Paper
Ask AI
Bookmark
Share

Why the study?

The comparative cardiovascular effectiveness of different RAS inhibitors in maintenance hemodialysis remains uncertain, with guidelines largely assuming therapeutic equivalence between ACEIs and ARBs.

Does initiation of ARB reduce 1-year major adverse cardiovascular events compared with ACEI in adults with ESKD receiving maintenance hemodialysis?

Population

55,894 adults with ESKD receiving maintenance hemodialysis

Comparison

Newly initiated ARB vs newly initiated ACEI therapy

Design

Propensity score-matched active-comparator new-user cohort study

Follow-up

1 year

Key result

Initiation of angiotensin receptor blockers was associated with a lower risk of 1-year major adverse cardiovascular events compared with ACEIs (30.3% vs. 35.0%; HR 0.85) in patients receiving maintenance hemodialysis.

Authors

JWJheng-Yan WuKLKeng-Wei LeeSHS H. M. Huang

Discussion

Loading...

Member takes

Overview

May support ARB over ACEI initiation in ESKD hemodialysis; leaves open confirmation by randomized trials.

Key Points

  • This study aims to assess the comparative cardiovascular effectiveness of RAS inhibitors in patients undergoing maintenance hemodialysis.
  • Utilized the TriNetX database to identify adults with end-stage kidney disease (ESKD) starting ARB or ACEI therapy from 2006 to 2025.
  • Applied 1:1 propensity score matching to create balanced comparison groups.
  • Estimated hazard ratios (HRs) for major adverse cardiovascular events (MACE) using Cox models.
  • After matching, 55,894 patients were analyzed, revealing ARB use associated with a 30.3% MACE rate vs. 35.0% for ACEI (HR 0.85; 95% CI 0.83–0.88).
  • Stroke risk was lower for ARB (HR 0.90; 95% CI 0.86–0.94) and all-cause mortality also lower (HR 0.75; 95% CI 0.71–0.78).
  • No significant difference in myocardial infarction risk (HR 0.99; 95% CI 0.94–1.03) and comparable hyperkalemia rates found.

Study Design

Type

Cohort (n=55,894)

Multicenter

Yes

Structured PICO

Does initiation of ARB reduce 1-year major adverse cardiovascular events compared with ACEI in adults with ESKD receiving maintenance hemodialysis?

P
Population
55,894 adults with end-stage kidney disease receiving maintenance hemodialysis who newly initiated ARB or ACEI therapy, followed for 1 year.
E
Exposure
Angiotensin receptor blockers (ARB) newly initiated
C
Comparator
Angiotensin-converting enzyme inhibitors (ACEI) newly initiated (1:1 propensity score matched active-comparator)
O
Outcome
1-year major adverse cardiovascular events (MACE: composite of myocardial infarction, stroke, or all-cause mortality)composite

Main Result

Hazard Ratio: 0.85 (95% CI 0.83–0.88)

Absolute Event Rate: 30.3% vs 35%

p-value: p=<0.001

In patients with ESKD on maintenance hemodialysis, initiating ARBs rather than ACEIs is associated with a lower 1-year risk of MACE, driven primarily by reductions in stroke and all-cause mortality.

Limitations

  • Potential for patient misclassification or underrepresentation in the registry-based database
  • Reliance on diagnostic and procedural coding introduces misclassification bias
  • Lack of detailed clinical data such as dialysis adequacy, blood pressure variability, and cause-specific mortality
  • Lack of information on medication dose, treatment adherence, or longitudinal treatment changes
  • Potential for residual confounding and indication bias
  • Potential selection bias from requiring a second prescription to confirm sustained treatment exposure
  • Composite endpoint included all-cause mortality rather than cardiovascular mortality
  • Relatively short follow-up duration of 1 year
  • Registry-based database with potential for patient misclassification or underrepresentation
  • Reliance on diagnostic and procedural coding
  • Lack of detailed clinical data including dialysis adequacy, blood pressure variability, and cause-specific mortality
  • Potential for residual confounding or selection bias due to observational design

Cite This Study

Wu et al. (2026) conducted a cohort in End-stage kidney disease (ESKD) receiving maintenance hemodialysis (n=55,894). Angiotensin receptor blockers (ARB) vs. Angiotensin-converting enzyme inhibitors (ACEI) was evaluated on 1-year major adverse cardiovascular events (MACE: myocardial infarction, stroke, or all-cause mortality) (HR 0.85, 95% CI 0.83-0.88, p=<0.001). Initiation of angiotensin receptor blockers was associated with a lower risk of 1-year major adverse cardiovascular events compared with ACEIs (30.3% vs. 35.0%; HR 0.85) in patients receiving maintenance hemodialysis.

synapsesocial.com/papers/6a35982fdd3be7785e70ec9dhttps://doi.org/10.3389/fphar.2026.1833065
View Full Paper
Ask AI
Bookmark
Share

Also Consider

Synapse has enriched 5 closely related papers on similar clinical questions. Consider them for comparative context:

  1. 1Comparative Effectiveness of Renin-Angiotensin System Antagonists in Maintenance Dialysis Patients2016 · 8 citations
  2. 2The effectiveness and safety of angiotensin-converting enzyme inhibition or receptor blockade in vascular diseases in patients with hemodialysis2017 · 2 citations
  3. 3Abstract FR431: Angiotensin-Converting Enzyme Inhibitors Versus Angiotensin II Receptor Blockers in Hypertensive Patients with Heart Failure: Insights from a Real-World Retrospective Cohort2025
  4. 4Comparative Effectiveness of Renin-Angiotensin System Inhibitors in Heart Failure With Nonreduced Ejection Fraction: A Multicenter Cohort Study2026
  5. 5Comparative effectiveness of angiotensin-converting enzyme inhibitors versus angiotensin II receptor blockers for major renal outcomes in patients with diabetes: A 15-year cohort study2017 · 33 citations