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Barriers to ACEI/ARB Use in Proteinuric Chronic Kidney Disease: An Observational Study

      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).

      Abbreviations and Acronyms:

      ACEI (angiotensin-converting enzyme inhibitor), AKI (acute kidney injury), ARB (angiotensin receptor blocker), CKD (chronic kidney disease), eGFR (estimated glomerular filtration rate), ICD-9/10 (International Classification of Diseases, Ninth/Tenth Revision), MRA (mineralocorticoid receptor antagonist), NSAID (nonsteroidal anti-inflammatory drug), RAAS (renin-angiotensin-aldosterone system), UACR (urinary albumin-creatinine ratio), UPCR (urinary protein-creatinine ratio)
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