Nephrology, dialysis, transplantation : official publication of the European Dialysis and Transplant Association - European Renal Association
August 12, 2026 · via Europe PMC
Renin-Angiotensin System Inhibition in Dialysis-Dependent Patients with Chronic Heart Failure due to Reduced Ejection Fraction: A Systematic Review and Meta-Analysis.
Sritharan A, Marchetti M, Antiochos P, +9 more, Lu H.
AI summary — for doctors, generated from the abstract only
In dialysis patients with HFrEF, ARNI and ACEi/ARB use were each associated with about 22-24% lower all-cause mortality in a meta-analysis of mostly observational studies.
What was studied
A systematic review and meta-analysis (to December 2025) of six ARNI studies (3,818 treated, 4,344 controls) and three ACEi/ARB studies (3,293 treated, 1,982 controls) in dialysis patients with chronic HFrEF.
Key findings
- ARNI vs non-ARNI: all-cause mortality HR 0.78 (95% CI 0.71-0.87)
- ACEi/ARB vs none: all-cause mortality HR 0.76 (0.68-0.84)
- ACEi/ARB: cardiovascular mortality HR 0.62; ARNI: HR 0.91 (not significant)
- ARNI studies suggested no excess hypotension and less hyperkalemia than ACEi/ARB
Clinical relevance
This supports a potential benefit of RAS blockade in dialysis patients with HFrEF, a group excluded from most trials, but as the authors stress, it does not demonstrate causal treatment effects.
Who should care
Limitations
Predominantly observational studies susceptible to residual confounding; safety data only from ARNI studies.
RAS blockers and ARNIs may help dialysis patients with HFrEF live longer, but randomized evidence is lacking.
This is an AI-generated summary of the published abstract, not a clinical recommendation. It may not reflect the full text or subsequent updates — verify against the original source before acting on it.
Abstract
Background and hypothesis
Evidence supporting renin-angiotensin system (RAS) inhibition in dialysis-dependent patients with heart failure with reduced ejection fraction (HFrEF) remains limited. We performed a systematic review and meta-analysis to assess the efficacy and safety of angiotensin receptor-neprilysin inhibitors (ARNIs) and angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (ACEi/ARBs) in this population (PROSPERO ID: CRD420251274393).
Methods
Outcomes of interest included all-cause mortality and cardiovascular mortality. Eligible studies included adult patients with chronic HFrEF on maintenance hemodialysis or peritoneal dialysis, comparing ARNI versus non-ARNI regimens and ACEi/ARB versus control regimens. Literature searches were conducted through December 2025 in PubMed, EMBASE, Google Scholar, and Web of Science. Hazard ratios (HRs) and their respective 95% confidence intervals (CIs) were pooled and meta-analyzed across studies.
Results
Overall, six studies evaluated ARNIs (3,818 treated; 4,344 controls), and three studies evaluated ACEi/ARBs (3,293 treated; 1,982 controls). ARNI use versus non-ARNI regimens was associated with significantly lower all-cause mortality (pooled HR 0.78, 95% CI 0.71-0.87), as was ACEi/ARB initiation versus placebo or no RAS blockade (pooled HR 0.76, 95% CI 0.68-0.84). ACEi/ARB therapy was also associated with lower cardiovascular mortality (pooled HR 0.62, 95% CI 0.54-0.71), whereas no significant association was observed with ARNIs (pooled HR 0.91, 95% CI 0.79-1.04). Safety data were available only for ARNI studies, suggesting no excess hypotension and a lower risk of hyperkalemia compared with ACEi/ARBs.
Conclusions
In dialysis-dependent patients with HFrEF, ARNI use versus non-ARNI regimens, and ACEi/ARB use versus placebo or no RAS blockade, were each associated with lower all-cause mortality, while lower cardiovascular mortality was observed only with ACEi/ARB therapy. These findings suggest a potential overall benefit of RAS blockade in this population; however, they are derived predominantly from observational studies, remain susceptible to residual confounding and should not be interpreted as demonstrating causal treatment effects.
DOI
10.1093/ndt/gfag184
PMID
42584660
Research metadata (titles, abstracts, authors, publication dates) is sourced from Europe PMC, which aggregates content from PubMed/MEDLINE, PubMed Central, and other providers under the U.S. National Library of Medicine (NLM/NCBI). NLM does not claim copyright on abstracts; the original journal publishers or authors may hold rights to the full articles. AI-generated summaries are derived only from the abstract, never the full text, and are always labeled as AI-generated.
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