Do ACEIs, ARBs Offer Atheroprotection in Lupus Nephritis?

SAN FRANCISCO, CA—Age at diagnosis of lupus nephritis and cumulative prednisone dose—not non-use of angiotensin converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs)—are the most important predictors for atherosclerotic cardiovascular events (CVEs), according to results of a case-control study presented at the 2015 ACR/ARHP Annual Meeting.

In patients with lupus nephritis, ACEIs and ARBs are used as adjuvant treatments for optimal control of proteinuria.

“However, it is not known if these agents have an atheroprotective effect, similar to that described in other at-risk populations, noted Konstantinos Tselios, MD, PhD, of the University of Toronto, Toronto Western Hospital, Toronto, ON, Canada.

To assess their atheroprotective role, Dr. Tselios and colleagues identified 144 patients with lupus nephritis enrolled in a longitudinal observation cohort study of the University of Toronto Lupus Clinic who had been treated with ACEIs/ARBs for at least 5 years for proteinuria. Mean age at disease onset was 34 years and mean follow-up time, 14.9 years. The majority (86%) were female. Patients with preexisting CVEs were excluded. The control group included 301 age-matched patients who did not receive ACEI/ARB treatment.

All patients were followed for the occurrence of atherosclerotic CVEs. This included transient ischemic attack (TIA) and stroke, angina, myocardial infarction (MI), percutaneous transluminal coronary angioplasty (PTCA), coronary artery bypass graft (CABG), congestive heart failure (CHF), pacemaker insertion, and peripheral vascular disease (PVD).

The investigators found no significant differences in cumulative occurrence of CVEs between the two groups: 9.7% for those treated with ACEIs/ARBs compared with 8.6% for untreated patients (P=0.708]. The treated patients, however, had fewer “hard events”: stroke, MI, CABG, and PTCA, 4.17% vs. 5.32%, respectively.

Specifically, among the 144 patients treated with ACEIs/ARBs, occurrence of CVEs included stroke (1 patient), angina (8), MI (3), PTCA (1), CABG (1), CHF (2), and PVD (1). There were no cases of TIA or pacemaker insertions.

Among the 301 patients who did not receive ACEIs/ARBs, CVEs included TIA (1 patient), stroke (6), angina (6), MI (5), PTCA (2), CABG (3), CHF (1), pacemaker insertion (2), and PVD (1).

Patients treated with ACEIs/ARBs had significantly more hypertension (100% vs. 52.8%; P<0.001) and diabetes (10.4% vs. 4.7%; P=0.021); in contrast, the controls had higher rates of hypercholesterolemia (27.9% vs. 18.1%; P=0.024) and elevated triglycerides (14% vs. 4.9%, P=0.004).

Regression analysis “failed to confirm ACEIs/ARBs non-use as an important predictor of future CVEs,” Dr. Tselios concluded.

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