ACE inhibitors/ARBs reduced kidney failure but not mortality in chronic kidney disease
Initiation of an angiotensin-converting enzyme (ACE) inhibitor or angiotensin-receptor blocker (ARB) reduced risk of progression to kidney failure by 34% among patients with a baseline estimated glomerular filtration rate (eGFR) below 30 mL/min/1.73 m2, a meta-analysis found.
Treatment with an angiotensin-converting enzyme (ACE) inhibitor or angiotensin-receptor blocker (ARB) protected against kidney failure in patients with advanced chronic kidney disease (CKD), but neither therapy provided a mortality benefit, according to a systematic review and meta-analysis.
The participant-level meta-analysis included 18 trials of patients with a baseline estimated glomerular filtration rate (eGFR) below 30 mL/min/1.73 m2 that compared the effects of ACE inhibitor or ARB treatment to other medications or placebo. The primary outcome was kidney failure with renal replacement therapy, and the secondary outcome was death before kidney failure. Subgroup analyses categorized patients by baseline age (<65 vs. ≥65 years), eGFR (<20 vs. ≥20 mL/min/1.73 m2), albuminuria (urine albumin–creatinine ratio <300 vs. ≥300 mg/g), and history of diabetes. The findings were published July 2 by Annals of Internal Medicine.
Among 1,739 participants, 624 (35.9%) developed kidney failure and 133 (7.6%) died, during a median follow-up of 34 months. ACE inhibitor or ARB treatment was associated with lower risk of kidney failure (adjusted hazard ratio, 0.66; 95% CI, 0.55 to 0.79) but not death (hazard ratio, 0.86; 95% CI, 0.58 to 1.28). There was no statistically significant interaction between ACE inhibitor or ARB treatment and age, eGFR, albuminuria, or diabetes. However, there was a signal toward less effect on renal failure in patients with diabetes.
Among other limitations, some of the included trials were completed more than a decade ago; individual participant data for hyperkalemia, acute kidney injury, and cardiovascular endpoints were not available; and the trials had few deaths with wide confidence intervals were wide. The study focused on the intention to start an ACE inhibitor or ARB in patients with advanced chronic kidney disease and does not show the effects of nonadherence to or discontinuation of the drugs.
Still, the study suggests that an ACE inhibitor or ARB may benefit patients with late-stage chronic kidney disease, the study authors wrote. "Even in an era where other agents, such as sodium–glucose cotransporter-2 inhibitors, are available, significant benefit can be derived from the initiation of ACE [inhibitor] or ARB treatment in patients with low GFR," they concluded.