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Higher Risk of Kidney Failure Associated With Angiotensin Receptor Blockers vs ACE Inhibitors in Patients With Heart

Hans J Moore1, Wen-Chih Wu2, Paul A Heidenreich3

  • 1Department of Medicine, Veterans Affairs Medical Center, Washington, DC; Department of Medicine, George Washington University, Washington, DC; Department of Medicine, Georgetown University, Washington, DC; Department of Medicine, Uniformed Services University, Washington, DC.

The American Journal of Medicine
|May 26, 2025
PubMed

Insights

For heart failure patients, angiotensin receptor blockers (ARBs) increase kidney failure risk compared to angiotensin-converting enzyme inhibitors (ACEIs). High-dose ARBs did not show a different risk, but did lower mortality risk.

Area of Science:

  • Cardiology
  • Nephrology
  • Pharmacology

Background:

  • Renin-angiotensin system (RAS) inhibition is crucial for managing heart failure.
  • High-dose ACEIs or ARBs are linked to reduced kidney failure risk in heart failure patients.
  • The comparative effect of ACEIs versus ARBs on kidney failure risk needs clarification.

Purpose of the Study:

  • To investigate whether the association between high-dose RAS inhibition and reduced kidney failure risk differs between ACEIs and ARBs.
  • To compare the incidence of kidney failure in heart failure patients treated with ACEIs versus ARBs.

Main Methods:

  • A propensity score-matched cohort of 88,178 heart failure patients initiated on ACEIs or ARBs was assembled.
  • The study analyzed 5-year kidney failure risk, defined as kidney replacement therapy or eGFR <15 mL/min/1.73m².
  • Hazard ratios were estimated, accounting for the competing risk of death.

Main Results:

  • Patients on ARBs had a 20% higher risk of kidney failure compared to those on ACEIs.
  • This increased risk was consistent across low-dose and high-dose subgroups.
  • ARBs were associated with a 5% lower risk of death, significant in the low-dose group.

Conclusions:

  • In heart failure patients, ARBs are associated with a higher risk of incident kidney failure compared to ACEIs.
  • These findings suggest a potential difference in renal protection between ACEIs and ARBs.
  • Further clinical trials are warranted to confirm these results.
Abstract

Keywords:
ACE inhibitorsAngiotensin receptor blockersHeart failureKidney failure

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