Benefits and harms of RAAS inhibition in adults with early chronic kidney disease
Chronic kidney disease (CKD) is a long-term condition characterised by a gradual loss of kidney function over time. The early diagnosis and treatment of CKD is important to prevent or delay both progression to the more advanced stages of the condition and the development of cardiovascular disease. Two classes of antihypertensive drugs – angiotensin-converting enzyme inhibitors (ACEis) and angiotensin receptor blockers (ARBs) – have been reported to have beneficial effects on kidney and cardiovascular outcomes and survival in the adult CKD population as a whole. Their benefits in people with early CKD are, however, less certain.
The current Cochrane Review set out to evaluate the benefits and harms of taking ACE or ARBs for the management of people with early CKD (stages 1 to 3), who do not have diabetes. The review identified six randomised controlled trials (9379 participants in total) of at least 4 weeks’ duration that reported the effects of ACEis or ARBs in adults meeting these criteria. Evidence from the studies was considered to be of low or very low quality, and at high risk of bias.
Compared to placebo, ACEis (benazepril or trandolapril) may reduce the chance of death, stroke, myocardial infarction and adverse events, but may or may not reduce the chance of congestive heart failure or transient ischaemic attack.
It is uncertain whether the ARB losartan reduces the chance of death, adverse events or presence of proteinuria, and it may not improve kidney function (eGFR) or blood pressure.
ACEis (enalapril, perindopril or trandolapril) may or may not be better than ARBs (olmesartan, losartan or candesartan) in reducing proteinuria and blood pressure.
The authors conclude that there is insufficient evidence to determine whether antihypertensive medications work better than placebo in adults with early CKD who do not have diabetes, or which class of medication is better than the other. This area of large uncertainty represents an area for future research.
The full review can be read here.
