Journal
AMERICAN JOURNAL OF KIDNEY DISEASES
Volume 67, Issue 5, Pages 728-741Publisher
W B SAUNDERS CO-ELSEVIER INC
DOI: 10.1053/j.ajkd.2015.10.011
Keywords
Angiotensin-converting enzyme (ACE) inhibitor; angiotensin II receptor blocker (ARB); renin angiotensin system (RAS) inhibition; chronic kidney disease (CKD); kidney failure; cardiovascular events; mortality; all-cause death; renal disease progression; blood pressure (BP); hypertension; comparative effectiveness; Bayesian network meta-analysis
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Funding
- National Natural Science Foundation of China [81270795, 2012CB517700, 81321064]
- Program for New Century Excellent Talents in University from the Ministry of Education of China [NCET-12-0011]
- Australian National Health and Medical Research Council
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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, 0.530.92). 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. (C) 2016 by the National Kidney Foundation, Inc.
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