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Renin-Angiotensin System Inhibitors and Kidney and Cardiovascular Outcomes in Patients With CKD: A Bayesian Network Meta-analysis of Randomized Clinical Trials

Published on May 1, 2016in American Journal of Kidney Diseases6.65
· DOI :10.1053/j.ajkd.2015.10.011
Xinfang Xie7
Estimated H-index: 7
(PKU: Peking University),
Youxia Liu4
Estimated H-index: 4
(PKU: Peking University)
+ 8 AuthorsHaiyan Wang41
Estimated H-index: 41
(PKU: Peking University)
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Abstract
Background There is much uncertainty regarding the relative effects of angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs) in populations with chronic kidney disease (CKD). Study Design Systematic review and Bayesian network meta-analysis. Setting & Population Patients with CKD treated with renin-angiotensin system (RAS) inhibitors. Selection Criteria for Studies Randomized trials in patients with CKD treated with RAS inhibitors. Predictor ACE inhibitors and ARBs compared to each other and to placebo and active controls. Outcome Primary outcome was kidney failure; secondary outcomes were major cardiovascular events, all-cause death. Results 119 randomized controlled trials (n=64,768) were included. ACE inhibitors and ARBs reduced the odds of kidney failure by 39% and 30% (ORs of 0.61 [95% credible interval, 0.47-0.79] and 0.70 [95% credible interval, 0.52-0.89]), respectively, compared to placebo, and by 35% and 25% (ORs of 0.65 [95% credible interval, 0.51-0.80] and 0.75 [95% credible interval, 0.54-0.97]), respectively, compared with other active controls, whereas other active controls did not show evidence of a significant effect on kidney failure. Both ACE inhibitors and ARBs produced odds reductions for major cardiovascular events (ORs of 0.82 [95% credible interval, 0.71-0.92] and 0.76 [95% credible interval, 0.62-0.89], respectively) versus placebo. Comparisons did not show significant effects on risk for cardiovascular death. ACE inhibitors but not ARBs significantly reduced the odds of all-cause death versus active controls (OR, 0.72; 95% credible interval, 0.53-0.92). Compared with ARBs, ACE inhibitors were consistently associated with higher probabilities of reducing kidney failure, cardiovascular death, or all-cause death. Limitations Trials with RAS inhibitor therapy were included; trials with direct comparisons of other active controls with placebo were not included. Conclusions Use of ACE inhibitors or ARBs in people with CKD reduces the risk for kidney failure and cardiovascular events. ACE inhibitors also reduced the risk for all-cause mortality and were possibly superior to ARBs for kidney failure, cardiovascular death, and all-cause mortality in patients with CKD, suggesting that they could be the first choice for treatment in this population.
  • References (139)
  • Citations (53)
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References139
Newest
Published on Dec 11, 2014in The New England Journal of Medicine70.67
Vicente E. Torres79
Estimated H-index: 79
,
Kaleab Z. Abebe17
Estimated H-index: 17
(University of Pittsburgh)
+ 14 AuthorsMarie C. Hogan31
Estimated H-index: 31
BACKGROUND Hypertension develops early in patients with autosomal dominant polycystic kidney disease (ADPKD) and is associated with disease progression. The renin–angiotensin–aldosterone system (RAAS) is implicated in the pathogenesis of hypertension in patients with ADPKD. Dual blockade of the RAAS may circumvent compensatory mechanisms that limit the efficacy of monotherapy with an angiotensin-converting–enzyme (ACE) inhibitor or angiotensin II–receptor blocker (ARB). METHODS In this double-bl...
Published on Dec 11, 2014in The New England Journal of Medicine70.67
Robert W. Schrier18
Estimated H-index: 18
(CU: University of Colorado Boulder),
Kaleab Z. Abebe17
Estimated H-index: 17
(University of Pittsburgh)
+ 15 AuthorsMarie C. Hogan31
Estimated H-index: 31
BACKGROUND Hypertension is common in autosomal dominant polycystic kidney disease (ADPKD) and is associated with increased total kidney volume, activation of the renin–angiotensin–aldosterone system, and progression of kidney disease. METHODS In this double-blind, placebo-controlled trial, we randomly assigned 558 hypertensive participants with ADPKD (15 to 49 years of age, with an estimated glomerular filtration rate [GFR] >60 ml per minute per 1.73 m 2 of body-surface area) to either a standar...
Published on Dec 1, 2014in American Journal of Kidney Diseases6.65
Krista Dybtved Kjaergaard5
Estimated H-index: 5
(AU: Aarhus University),
Christian D. Peters11
Estimated H-index: 11
(AU: Aarhus University)
+ 8 AuthorsCharlotte Strandhave5
Estimated H-index: 5
(AAU: Aalborg University)
Background Glomerular filtration rate (GFR) declines during long-term dialysis treatment. In peritoneal dialysis, blockade of the renin-angiotensin-aldosterone system reduces GFR decline. Observational studies suggest that similar treatment may preserve kidney function in hemodialysis (HD). Study Design A multicenter, randomized, placebo-controlled, double-blinded trial, with 1-year follow-up. Setting & Participants Adult HD patients with urine output >300mL/24h, HD vintage less than 1 year, and...
Published on Feb 5, 2014in JAMA51.27
Paul A. James21
Estimated H-index: 21
(UI: University of Iowa),
Suzanne Oparil94
Estimated H-index: 94
(UAB: University of Alabama at Birmingham)
+ 14 AuthorsOlugbenga Ogedegbe12
Estimated H-index: 12
(NYU: New York University)
Hypertension is the most common condition seen in primary care and leads to myocardial infarction, stroke, renal failure, and death if not detected early and treated appropriately. Patients want to be assured that blood pressure (BP) treatment will reduce their disease burden, while clinicians want guidance on hypertension management using the best scientific evidence. This report takes a rigorous, evidence-based approach to recommend treatment thresholds, goals, and medications in the managemen...
Published on Nov 14, 2013in The New England Journal of Medicine70.67
Linda F. Fried50
Estimated H-index: 50
(University of Pittsburgh),
Nicholas V. Emanuele31
Estimated H-index: 31
(LUC: Loyola University Chicago)
+ 13 AuthorsPaul M. Palevsky41
Estimated H-index: 41
(University of Pittsburgh)
Background Combination therapy with angiotensin-converting–enzyme (ACE) inhibitors and angiotensin-receptor blockers (ARBs) decreases proteinuria; however, its safety and effect on the progression of kidney disease are uncertain. Methods We provided losartan (at a dose of 100 mg per day) to patients with type 2 diabetes, a urinary albumin-to-creatinine ratio (with albumin measured in milligrams and creatinine measured in grams) of at least 300, and an estimated glomerular filtration rate (GFR) o...
Published on Nov 1, 2013in Hypertension Research3.22
Hiromi Rakugi64
Estimated H-index: 64
,
Toshio Ogihara91
Estimated H-index: 91
+ 10 AuthorsHiromichi Suzuki40
Estimated H-index: 40
Combination therapy for hypertension in patients with CKD: a subanalysis of the Combination Therapy of Hypertension to Prevent Cardiovascular Events trial
Published on Oct 24, 2013in BMJ27.60
Hon-Yen Wu13
Estimated H-index: 13
(NTU: National Taiwan University),
Jenq-Wen Huang27
Estimated H-index: 27
(NTU: National Taiwan University)
+ 6 AuthorsKuo-Liong Chien40
Estimated H-index: 40
(NTU: National Taiwan University)
Objective To assess the effects of different classes of antihypertensive treatments, including monotherapy and combination therapy, on survival and major renal outcomes in patients with diabetes. Design Systematic review and bayesian network meta-analysis of randomised clinical trials. Data sources Electronic literature search of PubMed, Medline, Scopus, and the Cochrane Library for studies published up to December 2011. Study selection Randomised clinical trials of antihypertensive therapy (ang...
Published on Jul 1, 2013in International Journal of Cardiology3.47
C. Barrett Bowling18
Estimated H-index: 18
(UAB: University of Alabama at Birmingham),
Paul W. Sanders45
Estimated H-index: 45
(UAB: University of Alabama at Birmingham)
+ 9 AuthorsGeorge Bakris2
Estimated H-index: 2
(U of C: University of Chicago)
Background Angiotensin-converting enzyme inhibitors improve outcomes in systolic heart failure (SHF). However, doubts linger about their effect in SHF patients with chronic kidney disease (CKD).
Published on Jun 1, 2013in Nephrology Dialysis Transplantation4.20
Kunitoshi Iseki59
Estimated H-index: 59
,
Hisatomi Arima47
Estimated H-index: 47
(The George Institute for Global Health)
+ 6 AuthorsShigeki Toma8
Estimated H-index: 8
Background. Hypertension is a major risk factor for death and cardiovascular disease (CVD) in patients undergoing chronic haemodialysis (HD), but there is uncertainty surrounding the effects of blood pressure (BP) lowering on this high-risk patient group. Methods. In a multicenter, prospective, randomized, open-label, blinded-endpoint trial, 469 patients with chronic HD and elevated BP (140–199/90–99 mmHg) were assigned to receive the angiotensin receptor blockade (ARB) olmesartan (at a dose of ...
Published on Apr 1, 2013in Evidence-based Medicine
Flávio Danni Fuchs6
Estimated H-index: 6
(NIST: National Institute of Standards and Technology)
Angiotensin receptor blockers (ARB) have been recommended as a first option for the management of hypertension by guidelines, particularly in patients at high cardiovascular risk. The preference for ARB in these conditions is based on their neutral metabolic effects, and on direct cardiac and renal protective effects independent of the blood pressure-lowering effect (pleiotropic effects). Nonetheless, six large clinical trials designed to demonstrate such effects in patients at high cardiovascul...
Cited By53
Newest
Published on Jul 18, 2019in Scientific Reports4.01
Hyeonjin Kang (SNU: Seoul National University), Song Hee Hong1
Estimated H-index: 1
(SNU: Seoul National University)
Polypharmacy, the concurrent use of multiple medicines, could increase the risk of kidney dysfunction among older adults because it likely burdens the aging kidneys to excrete multiple pharmaceutical ingredients and their metabolites. This study aimed to examine the relation between polypharmacy and kidney dysfunction among older patients. A nested case-control study was conducted using the National Health Insurance Service – Senior Cohort (NHIS-SC, 2009–2013), representative of the Korean senio...
Published on Jan 31, 2019in BMC Nephrology2.09
Marc Evans13
Estimated H-index: 13
(Cardiff University),
Marc Evans12
Estimated H-index: 12
+ 5 AuthorsAmeet Bakhai2
Estimated H-index: 2
(Royal Free Hospital)
People with chronic kidney disease (CKD) are at an increased risk of developing hyperkalaemia due to their declining kidney function. In addition, these patients are often required to reduce or discontinue guideline-recommended renin-angiotensin-aldosterone system inhibitor (RAASi) therapy due to increased risk of hyperkalaemia. This original research developed a model to quantify the health and economic benefits of maintaining normokalaemia and enabling optimal RAASi therapy in patients with CK...
Published on Dec 1, 2019in Renal Replacement Therapy
Minoru Ito , Yosuke Saka5
Estimated H-index: 5
+ 7 AuthorsHidetomo Nakamoto27
Estimated H-index: 27
Renin-angiotensin system inhibitors (RASIs), either angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, are widely used in patients with non-dialysis chronic kidney disease, as a renin-angiotensin system (RAS) blockade has renoprotective effects. Several studies show that preserving residual renal function is important for a better prognosis in peritoneal dialysis (PD) patients. Here, we systematically reviewed the beneficial or harmful effects of RAS blockade in PD patien...
Edouard Fu (KI: Karolinska Institutet), Marco Trevisan3
Estimated H-index: 3
(KI: Karolinska Institutet)
+ 6 AuthorsJuan Jesús Carrero58
Estimated H-index: 58
(KI: Karolinska Institutet)
Background and objectives Data from observational and interventional studies provide discordant results regarding the relationship between creatinine increase after renin-angiotensin system inhibition (RASi) and adverse outcomes. We compared health outcomes among patients with different categories of increase in creatinine upon initiation of RASi in a large population-based cohort. Design, setting, participants, & measurements We performed a retrospective analysis of the Stockholm CREAtinine Mea...
Published on 2019in Hypertension Research3.22
Umemura Satoshi48
Estimated H-index: 48
,
Hisatomi Arima47
Estimated H-index: 47
(Fukuoka University)
+ 7 AuthorsToshihiko Ishimitsu33
Estimated H-index: 33
(Dokkyo Medical University)
Published on Sep 1, 2019in Current Atherosclerosis Reports3.77
Sehrish Ali (BCM: Baylor College of Medicine), Natasha Dave (BCM: Baylor College of Medicine)+ 1 AuthorsSankar D. Navaneethan41
Estimated H-index: 41
(BCM: Baylor College of Medicine)
Purpose of Review Non-dialysis-dependent chronic kidney disease (NDD-CKD) patients are at an increased risk of cardiovascular disease (CVD)–related deaths in comparison with the general population. This review summarizes recent guideline recommendations and studies on primary and secondary prevention of traditional cardiovascular (CV) risk factors in those with NDD-CKD.
Published on 2019in Diabetic Medicine3.11
Craig I Coleman48
Estimated H-index: 48
(UConn: University of Connecticut),
E.R. Weeda (MUSC: Medical University of South Carolina)+ 2 AuthorsWilliam L. Baker28
Estimated H-index: 28
(UConn: University of Connecticut)
Sri Lekha Tummalapalli1
Estimated H-index: 1
(UCSF: University of California, San Francisco),
Neil R. Powe97
Estimated H-index: 97
(UCSF: University of California, San Francisco),
Salomeh Keyhani22
Estimated H-index: 22
(UCSF: University of California, San Francisco)
Background and objectives Improving the quality of CKD care has important public health implications to delay disease progression and prevent ESKD. National trends of the quality of CKD care are not well established. Furthermore, it is unknown whether gaps in quality of care are due to lack of physician awareness of CKD status of patients or other factors. Design, setting, participants, & measurements We performed a national, serial, cross-sectional study of visits to office-based ambulatory car...
Published on Oct 24, 2018in Acta Clinica Belgica0.96
Raymond Vanholder80
Estimated H-index: 80
,
W. Van Biesen12
Estimated H-index: 12
+ 0 AuthorsEvi V Nagler
ABSTRACTObjectives: In this publication, we review the definitions, symptoms, causes, differential diagnoses and therapies of hypokalemia and hyperkalemia. Methods: Comprehensive tables and diagnostic algorithms are provided when appropriate. Results and Conclusions: Although both hypokalemia and hyperkalemia may be life-threatening, this is essentially the case with severe changes (serum potassium 6.5 mmol/L), the presence of symptoms or electrocardiographic deviations, the association with agg...