ACE Inhibitors and ARBs After Dialysis-Requiring Acute Kidney Injury: A Focused Evidence Synthesis and Methodological Appraisal

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Background Survivors of dialysis-requiring acute kidney injury (AKI-D) remain at risk of death and adverse kidney outcomes. Angiotensin-converting enzyme inhibitors (ACE inhibitors) and angiotensin receptor blockers (ARBs) may remain indicated after AKI, but post-AKI-D evidence is limited and concerns include hypotension and hyperkalaemia. Objective To summarize observational evidence on post-AKI-D ACE inhibitor/ARB exposure and mortality, kidney outcomes, and adverse events, and assess whether available estimates can be pooled. Methods We examined an existing 277-record PubMed export and an evidence-extraction file, checking population relevance, exposure contrasts, outcomes, and possible cohort overlap. The original search string/date and complete multi-database search log were unavailable. Screening was single-reviewer and rule-assisted; the synthesis is descriptive. Results Four observational reports were considered directly or conditionally relevant: Yang et al. (2020), [Wu et al. (2022)](#ref-0002), Wu et al. (2025), and Chen and Li (2026). Reported adjusted mortality associations ranged from HR 0.64 in adults aged ≥85 years to HR 0.95 in a selected cohort alive and dialysis-independent beyond 180 days. Populations, exposure contrasts, and follow-up differed; potential overlap between Taiwan-based cohorts remains unresolved. The very-old cohort also reported higher hypotension and hyperkalaemia. No pooled estimate was calculated. Conclusion Observational studies suggest a possible association between post-AKI-D ACE inhibitor/ARB exposure and lower mortality in selected patients, but causal benefit is unproven. Clinical heterogeneity, unresolved cohort independence, and incomplete systematic-review procedures preclude defensible pooling at this stage.