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Renin-Angiotensin System Blockers and the Risk of COVID-19-Related Mortality in Patients with Kidney Failure
Maria Jose Soler1, Marlies Noordzij2, Daniel Abramowicz3,4
1Department of Nephrology, Vall d'Hebron University Hospital, Vall d'Hebron Institute of Research, Vall d'Hebron Barcelona Hospital Campus, Red de Investigación Renal (REDINREN), Barcelona, Spain.
Insights
This study found no increased mortality risk for kidney transplant recipients or dialysis patients with COVID-19 who used or discontinued angiotensin-converting enzyme inhibitors (ACEis) or angiotensin II receptor blockers (ARBs). These findings address concerns about ACEi/ARB use in vulnerable kidney disease populations during the pandemic.
Area of Science:
- Nephrology
- Infectious Diseases
- Pharmacology
Background:
- Concerns exist regarding potential negative impacts of ACE inhibitors (ACEis) and ARBs on COVID-19 outcomes.
- Patients with kidney failure, often prescribed ACEis/ARBs, face higher COVID-19 severity risks.
- Limited data exist on ACEi/ARB use and COVID-19 severity in kidney failure populations.
Purpose of the Study:
- To investigate the association between ACEi/ARB use and COVID-19 mortality in kidney transplant recipients and dialysis patients.
- To examine the impact of discontinuing ACEis/ARBs on COVID-19 mortality in these patient groups.
Main Methods:
- Utilized data from the European Renal Association COVID-19 database (ERACODA) for patients diagnosed between Feb 1 and Oct 1, 2020.
- Employed Cox proportional-hazards regression to assess 28-day mortality risk associated with ACEi/ARB use and discontinuation.
- Analyzed data from 1511 patients (459 transplant recipients, 1052 on dialysis).
Main Results:
- No significant association was found between ACEi/ARB use and 28-day mortality in either kidney transplant recipients or dialysis patients (adjusted HRs ~1.0-1.1).
- Discontinuation of ACEis/ARBs in transplant recipients showed a trend towards higher mortality, but this was not statistically significant after adjusting for COVID-19 severity.
- ACEi/ARB discontinuation was not associated with mortality in dialysis patients.
Conclusions:
- ACE inhibitor and ARB use is not significantly associated with increased 28-day mortality in kidney transplant recipients or dialysis patients with COVID-19.
- Discontinuation of these medications in the studied kidney disease populations with COVID-19 did not significantly impact mortality outcomes.
Background And Objectives:
There is concern about potential deleterious effects of angiotensin-converting enzyme inhibitors (ACEis) and angiotensin II receptor blockers (ARBs) in patients with coronavirus disease 2019 (COVID-19). Patients with kidney failure, who often use ACEis/ARBs, are at higher risk of more severe COVID-19. However, there are no data available on the association of ACEi/ARB use with COVID-19 severity in this population.
Design, Setting, Participants, & Measurements:
From the European Renal Association COVID-19 database (ERACODA), we retrieved data on kidney transplant recipients and patients on dialysis who were affected by COVID-19, between February 1 and October 1, 2020, and had information on 28-day mortality. We used Cox proportional-hazards regression to calculate hazard ratios for the association between ACEi/ARB use and 28-day mortality risk. Additionally, we studied the association of discontinuation of these agents with 28-day mortality.
Results:
We evaluated 1511 patients: 459 kidney transplant recipients and 1052 patients on dialysis. At diagnosis of COVID-19, 189 (41%) of the transplant recipients and 288 (27%) of the patients on dialysis were on ACEis/ARBs. A total of 88 (19%) transplant recipients and 244 (23%) patients on dialysis died within 28 days of initial presentation. In both groups of patients, there was no association between ACEi/ARB use and 28-day mortality in both crude and adjusted models (in transplant recipients, adjusted hazard ratio, 1.12; 95% confidence interval [95% CI], 0.69 to 1.83; in patients on dialysis, adjusted hazard ratio, 1.04; 95% CI, 0.73 to 1.47). Among transplant recipients, ACEi/ARB discontinuation was associated with a higher mortality risk after adjustment for demographics and comorbidities, but the association was no longer statistically significant after adjustment for severity of COVID-19 (adjusted hazard ratio, 1.36; 95% CI, 0.40 to 4.58). Among patients on dialysis, ACEi/ARB discontinuation was not associated with mortality in any model. We obtained similar results across subgroups when ACEis and ARBs were studied separately, and when other outcomes for severity of COVID-19 were studied, e.g., hospital admission, admission to the intensive care unit, or need for ventilator support.
Conclusions:
Among kidney transplant recipients and patients on dialysis with COVID-19, there was no significant association of ACEi/ARB use or discontinuation with mortality.
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