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Angiotensin-Converting Enzyme Inhibitor or Angiotensin Receptor Blocker Use and Renal Outcomes Prevalent User Designs May Overestimate Benefit

Laurie Tomlinson, MBBS, MRCP, PhD1; Liam Smeeth, MBChB, FRCGP, FFPH, FRCP, PhD1
[+] Author Affiliations
1Department of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, England
JAMA Intern Med. 2014;174(10):1706. doi:10.1001/jamainternmed.2014.1585.
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To the Editor The recent study by Hsu et al1 regarding the renoprotective effect of renin-angiotensin-aldosterone system blockade in patients with predialysis advanced chronic kidney disease, hypertension, and anemia is important but we believe that the findings should be interpreted with caution.

According to the way that angiotensin-converting enzyme inhibitor or angiotensin receptor blocker (ACEI/ARB) users were defined, people who had taken and then ceased ACEI/ARB therapy prior to the first erythropoiesis-stimulating agent (ESA) prescription would have been classified as nonusers. For a proportion of these participants, ACEI/ARB therapy may have been stopped for safety reasons, for example, to attempt to delay dialysis treatment.2 Indeed, 25% of those defined as nonusers received a prescription for ACEI/ARB in the 90 days prior to the first ESA prescription, and many “nonusers” had clear indications for ACEI/ARB therapy. This study design could create differential misclassification where those defined as ACEI/ARB users were more likely to have better kidney function or slower decline than those defined as nonusers. A “new user” design including all patients who initiate ACEI/ARB therapy rather than prevalent users may have led to less bias and provided a more balanced comparison.3


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October 1, 2014
Chih-Cheng Hsu, MD, DrPH; Jia-Sin Liu, MS; Der-Cherng Tarng, MD, PhD
1Division of Geriatrics and Gerontology, Institute of Population Health Sciences, National Health Research Institutes, Zhunan, Taiwan2Department of Health Services Administration, China Medical University and Hospital, Taichung, Taiwan
1Division of Geriatrics and Gerontology, Institute of Population Health Sciences, National Health Research Institutes, Zhunan, Taiwan
3Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan4Institutes of Physiology and Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
JAMA Intern Med. 2014;174(10):1706-1707. doi:10.1001/jamainternmed.2014.1578.
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