Should We Use ACE Inhibitors and ARBs in Patients with Advanced Chronic Kidney Disease?

Angiotensin-converting–enzyme (ACE) inhibitors or angiotensin-receptor blockers (ARBs) seldom are initiated among patients with chronic kidney disease (CKD) stage 4 or 5, despite guideline recommendations for these agents as first-line antihypertensive agents and to slow progression of CKD (NEJM JW Gen Med Dec 15 2017 and J Am Coll Cardiol 2018; 71:127). In a patient-level meta-analysis of 18 randomized trials, researchers identified 1700 patients with stage 4 or 5 CKD (estimated glomerular filtration rate [eGFR], <30 mL/minute/1.73 m²) to determine if initiating ACE inhibitors or ARBs affected progression to dialysis or death. Mean follow-up was ≈3 years.

Patients with CKD stage 4 or 5 (mean eGFR, 22 mL/minute/1.73 m²) who initiated ACE inh…