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Introduction: Niacin is a non-statin lipid-lowering therapy that has been shown to lower triglycerides and improve other risk factors for renal outcomes. Despite these favorable data, the effect of niacin on long-term kidney outcomes remains unclear. The aim of this study is to examine the associations of niacin therapies with incident chronic kidney disease (CKD), end-stage renal disease (ESRD), and death in patients with estimated glomerular filtration (eGFR) of at least 60 mL/min/1.73 m2., Methods: In a nationwide historic cohort of 1,139,630 US Veterans with normal baseline eGFR, we examined the association of de novo prescription of niacin with incident CKD (defined as eGFR <60 ml/min/1.73m2 on two occasions, separated by ≥90 days), ESRD (defined as the initiation of kidney replacement therapy), and death. Associations were examined in Cox proportional hazard models adjusted for demographics, major comorbidities, laboratory measurements, and medications. Prescription time-distribution matching was used to control for survival bias., Results: We identified 133,450 new users of niacin. Overall, patients (n=1,139,630) had a mean (standard deviation; SD) age of 60 (13) years, with 6% female, 78% White, 16% Black, and 6% Hispanic. Niacin users were more likely to be male, White, current, or former smokers, with higher frequencies of comorbidities and statin use. Niacin use (vs. non-use) was associated with a higher risk of CKD (HR: 1.08, 95% confidential interval [CI]:1.07-1.10) but a lower risk of ESRD (0.82, 0.76-0.88) and death (0.90, 0.89-0.91)., Conclusions: In a large national cohort of US Veterans with normal kidney function, niacin use was associated with a lower risk of ESRD and death but with a higher risk of incident CKD, which is potentially explained by acute effects on eGFR. Further studies are needed to corroborate the potential benefits of niacin on kidney function and survival., (S. Karger AG, Basel.)