Key result
ARB initiation linked to ~15% lower 1-year MACE risk vs ACEIs in hemodialysis patients.
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?
Cohort (n=55,894)
Yes
Does initiation of ARB reduce 1-year major adverse cardiovascular events compared with ACEI in adults with ESKD receiving maintenance hemodialysis?
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.
Answers are grounded in this paper and cite their sources.
May support ARB over ACEI initiation in ESKD hemodialysis; leaves open confirmation by randomized trials.
Background The comparative cardiovascular effectiveness of different renin–angiotensin system (RAS) inhibitors in patients receiving maintenance hemodialysis remains uncertain, and current guideline recommendations largely assume therapeutic equivalence between angiotensin-converting enzyme inhibitors (ACEI) and angiotensin receptor blockers (ARB). Methods Using the TriNetX multi-institutional database, we identified adults with ESKD who newly initiated ARB or ACEI therapy from 2006 to 2025. An active-comparator new-user design and 1:1 propensity score matching were applied. The primary outcome was 1-year major adverse cardiovascular events (MACE: myocardial infarction [MI], stroke, or all-cause mortality). Secondary outcomes included individual MACE components and hyperkalemia. Hazard ratios (HRs) were estimated using Cox models, and negative-control analyses assessed residual confounding. Results After matching, 55,894 patients were included. ARB was associated with a lower risk of MACE compared with ACEI users (30.3% vs. 35.0%; HR 0.85; 95% CI 0.83–0.88). Stroke (HR 0.90; 95% CI 0.86–0.94) and all-cause mortality (HR 0.75; 95% CI 0.71–0.78) were also associated with a lower risk, while MI risk was similar (HR 0.99; 95% CI 0.94–1.03). Hyperkalemia rates were comparable. Subgroup findings consistently favored ARBs across age, sex, diabetes, heart failure, CAD, and PAD strata. Negative-control outcomes showed no significant associations. Conclusion In this large real-world cohort of patients receiving maintenance hemodialysis, initiation of ARB was associated with lower risks of major adverse cardiovascular events, stroke, and all-cause mortality compared with ACEI. These findings suggest a potential difference in observed cardiovascular outcomes between ARBs and ACEIs in the hemodialysis population; however, causal inference is limited by the observational design.
No takes yet. Share an insight, caveat, or question.
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.
Synapse has enriched 10 related papers. Consider them for comparative context: