Adult Kidney Disease: Angiotensin Converting Enzyme (ACE) Inhibitor or

Measure Specification

This measure is aimed at increasing the number of patients with CKD and proteinuria who are prescribed ACE inhibitor or ARB therapy. ACE inhibitors and ARBs are preferred agents for diabetic kidney disease and nondiabetic kidney diseases with proteinuria (albuminuria), even in the absence of hypertension. In these diseases, ACE inhibitors and ARBs lower blood pressure, reduce proteinuria (albuminuria), slow the progression of kidney disease, and likely reduce cardiovascular disease risk by mechanisms in addition to lowering blood pressure.

These benefits have been shown across high quality, multi-center, randomized controlled trials such as RENAAL (Reduction of Endpoints in NIDDM with the Angiotensin II Antagonist Losartan). A meta-analysis of randomized trials showed that ACEi/ARB therapy lowered the odds of kidney failure (also known as end-stage renal disease [ESRD]) by 30-39 percent and of cardiovascular disease events by 18 percent-24 percent.

In a meta-analysis including primarily diabetic patients with proteinuria, use of ACEi/ARB therapy had a 0.36 to 0.78 odds of incident kidney failure. Similarly, in a Cochrane meta-analysis, patients with early (stage 1 to 3) non-diabetic CKD who were treated versus not treated with ACEi/ARB had 31 percent lower risk of kidney failure. Based upon this robust evidence, ACE inhibitors and ARBs are recommended for patients with CKD and proteinuria by the Kidney Disease: Improving Global Outcomes (KDIGO) international guidelines and the Kidney Disease Outcomes Quality Initiative.

CKD is a major public health problem; a total of 37 million Americans have CKD. There is a clear performance gap in ACE inhibitor and ARB usage among patients with CKD, with only 40 percent of CKD patients receiving an ACEi/ARB in NHANES data. Population health efforts to increase the use of ACEi/ARB in American Indians and Alaska Natives have been associated with a decrease in incident kidney failure related to diabetic kidney disease.

In summary, this measure is a central component of high-quality nephrology care, as ACE inhibitors and ARBs decrease the rate of kidney failure, cardiovascular outcomes, and mortality in patients with CKD and proteinuria.

Clinical practice guidelines support the use of ACE and ARB in CKD patients not on RRT. The Kidney Disease Improving Global Outcomes (KDIGO) 2012 guidelines for the evaluation and management of CKD recommend that “an ARB or ACE-I be used in both diabetic and non-diabetic adults with CKD and urine albumin excretion > 300 mg/24 hours (or equivalent)” (Recommendation 3.

1.7, 1B). Guideline available at https://kdigo.org/wp- content/uploads/2017/02/KDIGO_2012_CKD_GL.pdf. The KDIGO 2021 Clinical Practice Guideline on the Management of Blood Pressure (BP) in CKD recommends “starting renin-angiotensin-system inhibitors (RASi) (ACEi or ARB) for people with high BP, CKD, and severely increased albuminuria (G1–G4, A3) without diabetes” and “for people with high BP, CKD, and moderately-to-severely increased albuminuria (G1–G4, A2 and A3) with diabetes” (Recommendations 3.

2.1 and 3.2.3, 1B). Guideline available at https://kdigo.org/wp-content/uploads/2016/10/KDIGO-2021-BP-GL.pdf. This measure was rated as HIGH for Overall Measure Validity in Mendu ML, Tummalapalli SL, Lentine KL, Erickson KF, Lew SQ, Liu F, Gould E, Somers M, Garimella PS, O'Neil T, White DL, Meyer R, Bieber SD, Weiner DE. Measuring Quality in Kidney Care: An Evaluation of Existing Quality Metrics and Approach to Facilitating Improvements in Care Delivery.

J Am Soc Nephrol. 2020 Mar;31(3):602-614. doi: 10.1681/ASN.2019090869. Epub 2020 Feb 13. PMID: 32054692; PMCID: PMC7062216.

This measure contains one strata defined by a single submission criteria. This measure produces a single performance rate. For the purposes of MIPS implementation, this patient-process measure is submitted a minimum of once per patient for the performance period. The most advantageous quality data code (QDC) will be used if the measure is submitted more than once.