BackgroundThe comparative cardiovascular effectiveness of different renin–angiotensin system (RAS) inhibitors in patients receiving maintenance hemodialysis remains uncertain, and current guideline recommendations largely assume therapeutic equivalence between angiotensin-converting enzyme inhibitors (ACEI) and angiotensin receptor blockers (ARB).MethodsUsing the TriNetX multi-institutional database, we identified adults with ESKD who newly initiated ARB or ACEI therapy from 2006 to 2025. An act