Is Combined Angiotensin-converting Enzyme Inhibition and Angiotensin Receptor Blockade Associated with Increased Risk of Cardiovascular Death in Hemodialysis Patients?
Macaulay A. C. Onuigbo,
Nnonyelum T.C. Onuigbo.
There is a global ESRD pandemic. Despite all therapeutic maneuvers and advances in dialysis care over the last
two decades, ESRD patients on hemodialysis continue to experience high all-cause and cardiovascular mortality, with
annual mortality rates exceeding 20%. There have been attempts to show that combination angiotensin converting enzyme
inhibition and angiotensin receptor blockade therapy will help resolve this overwhelming cardiovascular mortality among
hemodialysis patients. We present here, a balanced review of current knowledge on the benefits and pitfalls of the use of
combination angiotensin converting enzyme inhibition and angiotensin receptor blockade in this vulnerable patient
population. We conclude that there is no quick simple fix to the high cardiovascular mortality in hemodialysis patients.
Combination angiotensin converting enzyme inhibition and angiotensin receptor blockade has not and will not solve the
quagmire. Cardiovascular mortality among hemodialysis patients, clearly very high, is under the influence of just too
many confounding factors and variables. Thus, in our mind, only through a concerted multifaceted approach, targeting all
the variables discussed in this review, and more, and most importantly, with significant flexibility to individualize and
tailor therapies as they are applicable and tolerated by specific individual patients, would we even begin to dent the high
cardiovascular mortality among hemodialysis patients. A simple randomized placebo-controlled trial, just targeting one
plausible etiologic factor, in our opinion, will hardly prove any more useful than previous such trials have demonstrated in
Keywords: Angiotensin converting enzyme inhibitor, angiotensin receptor blocker, hemodialysis, end stage renal disease,
combination angiotensin blockade, hypertension
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