Antihypertensive treatment for kidney transplant recipients

Abstract

BackgroundIn some nontransplant populations, e ects of di erent antihypertensive drug classes vary. Relative e ects in kidney transplant recipients are uncertain. ObjectivesTo assess comparative e ects of di erent classes of antihypertensive agents in kidney transplant recipients. Search methodsMEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, conference proceedings and reference lists of identified studies were searched. Selection criteriaRandomised controlled trials of any antihypertensive agent applied to kidney transplant recipients for at least two weeks were included. Data collection and analysisData was extracted by two investigators independently. Study quality, transplant outcomes and other patient centred outcomes were assessed using random e ects meta-analysis. Risk ratios (RR) for dichotomous outcomes and mean di erence (MD) for continuous outcomes, both with 95% confidence intervals (CI) were calculated. Stratified analyses and meta-regression were used to investigate heterogeneity. Main resultsWe identified 60 studies, enrolling 3802 recipients. Twenty-nine studies (2262 participants) compared calcium channel blockers (CCB) to placebo/no treatment, 10 studies (445 participants) compared angiotensin converting enzyme inhibitors (ACEi) to placebo/no treatment and seven studies (405 participants) compared CCB to ACEi. CCB compared to placebo/no treatment (plus additional agents in either arm as required) reduced gra loss (RR 0.75, 95% CI 0.57 to 0.99) and improved glomerular filtration rate (GFR), (MD, 4.45 mL/min, 95% CI 2.22 to 6.68). Data on ACEi versus placebo/no treatment were inconclusive for GFR (MD -8.07 mL/min, 95% CI -18.57 to 2.43), and variable for gra loss, precluding meta-analysis. In direct comparison with CCB, ACEi decreased GFR (MD -11.48 mL/min, 95% CI -5.75 to -7.21), proteinuria Antihypertensive treatment for kidney transplant recipients (Review)

Posttransplantation Proteinuria

“…In these two trials, there was no significant effect of calcium channel blockade compared with placebo on 24-hour protein excretion (mean difference 0.03 g/d; 95% CI Ϫ0.25 to 0.32) (50). Despite the lack of effect on proteinuria, calcium channel blockers (n ϭ 17 trials involving 1255 patients) were associated with a 25% reduction in graft loss compared with placebo or no treatment (RR 0.75; 95% CI 0.57 to 0.99; P ϭ 0.04) (50).…”

“…A recent systematic review from the Cochrane Renal Group analyzed all antihypertensive trials in kidney transplantation (50). Of 60 trials located in the review, only two (n ϭ 90 patients) evaluated the effect of calcium channel blockers on proteinuria.…”

“…In the previously mentioned Cochrane systematic review, ACEIs were compared with placebo/no treatment in three trials in which proteinuria was reported (n ϭ 175 patients) (50). In these trials, there was no significant effect on proteinuria reduction with an ACEI (mean difference Ϫ0.08 g/d; 95% CI Ϫ0.23 to 0.06 g/d).…”

“…In these trials, there was no significant effect on proteinuria reduction with an ACEI (mean difference Ϫ0.08 g/d; 95% CI Ϫ0.23 to 0.06 g/d). When calcium channel blockers were compared with ACEIs (n ϭ 2 trials involving 142 patients), patients on calcium channel blockers had a significantly higher proteinuria (mean difference 0.28 g/d; 95% CI 0.10 to 0.47 g/d) (50). The use of ACEIs in transplantation is not without consequence; patients who were on these medications (n ϭ 5 trials; 265 patients) had a significantly lower hemoglobin level compared with patients who were receiving a calcium channel blocker (mean difference 11.5 g/L; 95% CI 7.2 to 15.8) (50).…”

“…When calcium channel blockers were compared with ACEIs (n ϭ 2 trials involving 142 patients), patients on calcium channel blockers had a significantly higher proteinuria (mean difference 0.28 g/d; 95% CI 0.10 to 0.47 g/d) (50). The use of ACEIs in transplantation is not without consequence; patients who were on these medications (n ϭ 5 trials; 265 patients) had a significantly lower hemoglobin level compared with patients who were receiving a calcium channel blocker (mean difference 11.5 g/L; 95% CI 7.2 to 15.8) (50). Because of a small number of trials and heterogeneity in the data, no conclusive statement could be made about the effect of ACEIs on mortality or graft survival (50).…”