Kidney Outcomes After ARNI Versus ACEI/ARB for mHTN-Related TMA 

Jianbo Li, MD, and colleagues conducted a single-center cohort study to evaluate kidney outcomes of angiotensin receptor-neprilysin inhibitor (ARNI) compared to angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) treatment for patients with thrombotic microangiopathy (TMA) related to malignant hypertension (mHTN). 

The study included 217 patients in China diagnosed with mHTN-associated TMA by kidney biopsy from January 2008 to June 2023. Their mean  (SD) age was 35.9 (8.8) years, and 188 (86.6%) were men. Follow-up extended through the conclusion of the study period.  

The primary outcome was a composite of kidney recovery (a 50% decrease in serum creatinine level, decrease in serum creatinine levels to the reference range, or kidney survival free from dialysis for more than one month). The secondary outcome was a 15% increase in eGFR relative to baseline. The tertiary outcome was kidney survival free from dialysis. The researchers used propensity score matching and Cox proportional hazards regression analysis to assess the association between ARNI (specifically, sacubitril/valsartan) or ACEI/ARB therapy and kidney recovery outcomes. 

Sixty-six (30.4%) patients received sacubitril/valsartan and 151 (69.6%) received ACEI/ARBs at baseline. The ARNI treatment was associated with a shorter time to the primary outcome compared to ACEI/ARB treatment (20/63 [31.7%] vs 38/117 [32.5%]; adjusted HR [aHR], 1.85; 95% CI, 1.05-3.23).  

ARNI was also independently associated with a shorter time to a 15% increase in eGFR (15/46 [32.6%] vs 46/83 [55.4%]; aHR, 2.13; 95% CI, 1.09-4.17) and kidney survival free from dialysis (11 of 23 [47.8%] vs 16 of 57 [28.1%]; aHR, 2.63; 95% CI, 1.15-5.88) compared to ACEI/ARB treatment. The differences were also significant in the propensity score matching comparison. 

Compared to ACEI/ARB treatment, sacubitril/valsartan treatment was associated with possible kidney function benefits in patients with mHTN-associated TMA and could be a better therapeutic approach regarding kidney recovery. 

Source: JAMA Network Open.