ACE Inhibitors and ARBs vs. Other Antihypertensives for Renoprotection

Bruce Soloway, MD

Journal Watch. 2006;5(1) 

Angiotensin-converting–enzyme (ACE) inhibitors or angiotensin-receptor blockers (ARBs) are recommended widely as first-line treatments for hypertension in patients with diabetic or nondiabetic nephropathy. How strong is the evidence that these drugs are more renoprotective than other antihypertensive agents?

In a meta-analysis, investigators reviewed 127 randomized controlled trials in which ACE inhibitors or ARBs were compared with other antihypertensive agents or placebo for prevention of renal disease. End-stage renal disease (ESRD) or doubling of serum creatinine levels were considered to be primary outcomes; secondary outcomes were changes in glomerular filtration rate (GFR), serum creatinine levels, and albuminuria.

Mean follow-up was 4.2 years. When diabetics and nondiabetics were analyzed together, ACE inhibitors or ARBs were significantly more effective than other antihypertensives in reducing ESRD incidence, serum creatinine levels, and albuminuria, but they had no significant effect on preventing doubling of serum creatinine or reduction in GFR. In diabetics, ACE inhibitors or ARBs were significantly more effective than other antihypertensives only in reducing albuminuria; in nondiabetics, ACE inhibitors or ARBs were more effective than other agents only in reducing albuminuria and serum creatinine levels. When ACE inhibitors or ARBs were compared with other agents or placebo for prevention of ESRD, reduced incidence of ESRD was associated strongly with reduction in blood pressure.

Experts continue to debate whether different classes of antihypertensives have specific cardioprotective effects or whether they all improve cardiac outcomes primarily by reducing blood pressure. These findings extend that debate to kidney function and challenge accepted dogma about renin-angiotensin blockade, especially in diabetics. The authors call for larger studies with better control for blood pressure differences.

— Bruce Soloway, MD

Casas JP et al. Effect of inhibitors of the renin-angiotensin system and other antihypertensive drugs on renal outcomes: Systematic review and meta-analysis. Lancet 2005 Dec 10; 366:2026-33.


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