Are Renin–Angiotensin–Aldosterone System Inhibitors Lifesaving in Chronic Kidney Disease?

The recently updated Kidney Disease Improving Global Outcomes clinical practice guideline on CKD and blood pressure recommends treatment with ACEI and ARB as first-line therapy in patients with concomitant hypertension and microalbuminuria or macroalbuminuria to slow the progression of CKD (7). Because most (if not all) patients with CKD have hypertension (or blood pressures greater than the target range of 130/80 mm Hg), these therapies are indicated in the majority of patients. Because CKD is often prevalent in diseases such as coronary artery disease, hypertension, and heart failure, and RAAS inhibitor therapy has been associated with improved cardiovascular outcomes in these populations, it is also less surprising that mortality benefit particularly was observed in these subgroups. [...]any therapy in CKD that prolongs survival potentially increases the likelihood of dialysis because patients live longer and thus have a higher chance to progress to end-stage renal disease, which obviously affects quality of life. [...]studies that evaluate the effect of interventions in CKD should analyze death (or more specifically, cardiovascular death) and end-stage renal disease together as competing events.