Ian E McCoy1, Jialin Han2, Maria E Montez-Rath2, Glenn M Chertow2. 1. Division of Nephrology, University of California, San Francisco, CA. Electronic address: ian.mccoy@ucsf.edu. 2. Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA.
Abstract
OBJECTIVE: To assess present angiotensin-converting enzyme inhibitor (ACEI) and angiotensin receptor blocker (ARB) use among patients with proteinuric chronic kidney disease (CKD) and examine barriers limiting this guideline-concordant care. PATIENTS AND METHODS: Using a nationwide database containing patient-level claims and integrated clinical information, we examined current ACEI/ARB prescriptions on the index date (April 15, 2017) and prior ACEI/ARB use in 41,743 insured adults with proteinuric CKD. Using multivariable logistic regression, we estimated adjusted associations between current ACEI/ARB use and putative barriers including past acute kidney injury (AKI), hyperkalemia, advanced CKD, and lack of nephrology care. RESULTS: Only 49% (n=20,641) of patients had an active ACEI/ARB prescription on the index date, but 87% (n=36,199) had been previously prescribed an ACEI/ARB. Use was lower in patients with past AKI, hyperkalemia, CKD stages 4 or 5, and a lack of nephrology care (adjusted odds ratios were 0.61 [95% CI, 0.58 to 0.64], 0.76 [95% CI, 0.72 to 0.80], 0.48 [95% CI, 0.45 to 0.51], and 0.85 [95% CI, 0.81 to 0.89], respectively). CONCLUSION: Discontinuing, rather than never initiating, ACEI/ARB treatment limits guideline-concordant care in proteinuric CKD. Past AKI, hyperkalemia, advanced CKD, and lack of nephrology care were associated with lower use of ACEIs/ARBs, but these putative barriers may in many instances be inappropriate (AKI and advanced CKD) or modifiable (hyperkalemia and lack of nephrology care).
OBJECTIVE: To assess present angiotensin-converting enzyme inhibitor (ACEI) and angiotensin receptor blocker (ARB) use among patients with proteinuric chronic kidney disease (CKD) and examine barriers limiting this guideline-concordant care. PATIENTS AND METHODS: Using a nationwide database containing patient-level claims and integrated clinical information, we examined current ACEI/ARB prescriptions on the index date (April 15, 2017) and prior ACEI/ARB use in 41,743 insured adults with proteinuric CKD. Using multivariable logistic regression, we estimated adjusted associations between current ACEI/ARB use and putative barriers including past acute kidney injury (AKI), hyperkalemia, advanced CKD, and lack of nephrology care. RESULTS: Only 49% (n=20,641) of patients had an active ACEI/ARB prescription on the index date, but 87% (n=36,199) had been previously prescribed an ACEI/ARB. Use was lower in patients with past AKI, hyperkalemia, CKD stages 4 or 5, and a lack of nephrology care (adjusted odds ratios were 0.61 [95% CI, 0.58 to 0.64], 0.76 [95% CI, 0.72 to 0.80], 0.48 [95% CI, 0.45 to 0.51], and 0.85 [95% CI, 0.81 to 0.89], respectively). CONCLUSION: Discontinuing, rather than never initiating, ACEI/ARB treatment limits guideline-concordant care in proteinuric CKD. Past AKI, hyperkalemia, advanced CKD, and lack of nephrology care were associated with lower use of ACEIs/ARBs, but these putative barriers may in many instances be inappropriate (AKI and advanced CKD) or modifiable (hyperkalemia and lack of nephrology care).
Authors: Ezra A Amsterdam; Nanette K Wenger; Ralph G Brindis; Donald E Casey; Theodore G Ganiats; David R Holmes; Allan S Jaffe; Hani Jneid; Rosemary F Kelly; Michael C Kontos; Glenn N Levine; Philip R Liebson; Debabrata Mukherjee; Eric D Peterson; Marc S Sabatine; Richard W Smalling; Susan J Zieman Journal: J Am Coll Cardiol Date: 2014-09-23 Impact factor: 24.094
Authors: Mallika L Mendu; Sri Lekha Tummalapalli; Krista L Lentine; Kevin F Erickson; Susie Q Lew; Frank Liu; Edward Gould; Michael Somers; Pranav S Garimella; Terrence O'Neil; David L White; Rachel Meyer; Scott D Bieber; Daniel E Weiner Journal: J Am Soc Nephrol Date: 2020-02-13 Impact factor: 10.121
Authors: B M Brenner; M E Cooper; D de Zeeuw; W F Keane; W E Mitch; H H Parving; G Remuzzi; S M Snapinn; Z Zhang; S Shahinfar Journal: N Engl J Med Date: 2001-09-20 Impact factor: 91.245
Authors: G L Bakris; M Siomos; D Richardson; I Janssen; W K Bolton; L Hebert; R Agarwal; D Catanzaro Journal: Kidney Int Date: 2000-11 Impact factor: 10.612
Authors: Murray Epstein; Nancy L Reaven; Susan E Funk; Karen J McGaughey; Nina Oestreicher; John Knispel Journal: Am J Manag Care Date: 2015-09 Impact factor: 2.229
Authors: Paul K Whelton; Robert M Carey; Wilbert S Aronow; Donald E Casey; Karen J Collins; Cheryl Dennison Himmelfarb; Sondra M DePalma; Samuel Gidding; Kenneth A Jamerson; Daniel W Jones; Eric J MacLaughlin; Paul Muntner; Bruce Ovbiagele; Sidney C Smith; Crystal C Spencer; Randall S Stafford; Sandra J Taler; Randal J Thomas; Kim A Williams; Jeff D Williamson; Jackson T Wright Journal: Hypertension Date: 2017-11-13 Impact factor: 9.897
Authors: Michael H Chiu; Robert J H Miller; Rebecca Barry; Bing Li; Bryan J Har; Stephen B Wilton; Merril Knudtson; Jonathan G Howlett; Matthew T James Journal: Can J Kidney Health Dis Date: 2018-10-15
Authors: Toshiaki Ohkuma; Katie Harris; Mark Cooper; Diederick E Grobbee; Pavel Hamet; Stephen Harrap; Giuseppe Mancia; Michel Marre; Anushka Patel; Anthony Rodgers; Bryan Williams; Mark Woodward; John Chalmers Journal: Clin J Am Soc Nephrol Date: 2022-07-27 Impact factor: 10.614
Authors: Min Zhuo; Jiahua Li; Leo F Buckley; Sri Lekha Tummalapalli; David B Mount; David J R Steele; David J Lucier; Mallika L Mendu Journal: Kidney360 Date: 2022-01-19