Clinical outcomes associated with ACE inhibitors and ARBs use in adults older than 85 years who recovered from dialysis‐requiring acute kidney injury

Aim Angiotensin‐Converting Enzyme inhibitors/Angiotensin II Receptor Blockers (ACEi/ARB) therapy is recommended to improve outcomes after acute kidney injury (AKI). However, data on their effects in very old adults after AKI remain limited. Methods This cohort study utilized data from TriNetX, including adults aged ≥85 years who underwent dialysis during hospitalization and discontinued dialysis upon discharge between 2012 and 2022. Patients initiating ACEi/ARB within 90 days post‐discharge were identified and propensity score–matched (1:1) with controls. Outcomes, including mortality, major adverse kidney events (MAKE) and major adverse cardiovascular events (MACE), were analysed using Cox proportional hazards models in an emulated target trial analysis. Results Among 88 024 patients, 3637 ACEi/ARB users were matched to 3637 controls, with a mean follow‐up of 9.02 months. ACEi/ARB use was associated with a significantly lower risk of all‐cause mortality (aHR = 0.64; p < 0.01) and MAKE (aHR = 0.63; p < 0.01). No significant difference was observed in MACE between groups (aHR = 0.94; p = 0.49). The observed protective effect of ACEi/ARB on MAKE was more pronounced in patients with hypertension. ACEi/ARB use was associated with a higher risk of hypotension (aHR = 1.38; p < 0.01) and hyperkalaemia (aHR = 1.69; p < 0.01). Conclusion Among very old adults after dialysis for AKI, the ACEi/ARB therapy was significantly associated with lower risks of all‐cause mortality and MAKE, but with a significantly increased risk of hypotension and hyperkalaemia. These findings support the cautious use of ACEi/ARB in this high‐risk population.