Combination Therapy With an Angiotensin Receptor Blocker and an ACE Inhibitor in Proteinuric Renal Disease: A Systematic Review of the Efficacy and Safety Data

MacKinnon, Martin; Shurraw, Sabin; Akbari, Ayub; Knoll, Greg; Jaffey, James; Clark, Heather D.

doi:10.1053/j.ajkd.2006.04.077

Cited by 219 publications

(134 citation statements)

References 47 publications

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“…There is also strong evidence that proteinuria reduction reduces the risk of CKD progression (29,30). ACE-Is and ARBs reduce proteinuria independently of BP (31,32). Large studies have shown that achieving a hemoglobin A1c level#7% reduces proteinuria and the risk of CKD (33,34).…”

Section: Discussionmentioning

confidence: 99%

Implementation of a CKD Checklist for Primary Care Providers

Mendu

Schneider

Aizer³

et al. 2014

Clinical Journal of the American Society of Nephrology

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Background and objectives CKD is associated with significant morbidity, mortality, and financial burden. Practice guidelines outlining CKD management exist, but there is limited application of these guidelines. Interventions to improve CKD guideline adherence have been limited. This study evaluated a new CKD checklist (a tool outlining management guidelines for CKD) to determine whether implementation in an academic primary care clinic improved adherence to guidelines.Design, setting, participants, & measurements During a 1-year period (August 2012-August 2013), a prospective study was conducted among 13 primary care providers (PCPs), four of whom were assigned to use a CKD checklist incorporated into the electronic medical record during visits with patients with CKD stages 1-4. All providers received education regarding CKD guidelines. The intervention and control groups consisted of 105 and 263 patients, respectively. Adherence to CKD management guidelines was measured.Results A random-effects logistic regression analysis was performed to account for intra-group correlation by PCP assignment and adjusted for age and CKD stage. CKD care improved among patients whose PCPs were assigned to the checklist intervention compared with controls. Patients in the CKD checklist group were more likely than controls to have appropriate annual laboratory testing for albuminuria (odds ratio [OR], 7.9; 95% confidence interval [95% CI], 3.6 to 17.2), phosphate (OR, 3.5; 95% CI, 1.5 to 8.3), and parathyroid hormone (OR, 8.1; 95% CI, 4.8 to 13.7) (P,0.001 in all cases). Patients in the CKD checklist group had higher rates of achieving a hemoglobin A1c target,7% (OR, 2.7; 95% CI, 1.4 to 5.1), use of an angiotensin-converting enzyme inhibitor or angiotensin-receptor blocker (OR, 2.1; 95% CI, 1.0 to 4.2), documentation of avoidance of nonsteroidal anti-inflammatory drugs (OR, 41.7; 95% CI, 17.8 to 100.0), and vaccination for annual influenza (OR, 2.1; 95% CI, 1.1 to 4.0) and pneumococcus (OR, 4.7; 95% CI, 2.6 to 8.6) (P,0.001 in all cases).Conclusions Implementation of a CKD checklist significantly improved adherence to CKD management guidelines and delivery of CKD care.

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Section: Discussionmentioning

confidence: 99%

Implementation of a CKD Checklist for Primary Care Providers

Mendu

Schneider

Aizer³

et al. 2014

Clinical Journal of the American Society of Nephrology

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“…If multiple drug therapy is required, diuretics and calcium channel blockers are the most suitable addition to a RAS blocker . Whereas the combined administration of ACE inhibitors, ARBs and the renin inhibitor aliskiren exert additional antiproteinuric effects in adults and children (233,234), it is recommended not to use such combination therapies because of increased rates of serious adverse events such as acute kidney injury and hyperkalemia observed in large randomized trials of high-risk adult patients (219-221).…”

Section: Non-diabetic Renal Diseasementioning

confidence: 99%

2016 European Society of Hypertension guidelines for the management of high blood pressure in children and adolescents

Lurbe

Agabiti‐Rosei

Cruickshank

et al. 2016

Journal of Hypertension

1,086

1,063

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“…2 Nevertheless, a significant proportion of CKD patients continue to deteriorate and develop end-stage renal disease even with optimization of ACEI and/or ARB therapy. Despite the early enthusiasm from multiple small, uncontrolled studies, which showed a significant reduction in proteinuria by ACEI and ARB combination therapy, 3 a recent large-scale randomized controlled study showed that combination of ramipril and telmisartan was associated with more adverse events without an increase in benefit when compared with either treatment alone. 4 Although the combination of ramipril and telmisartan did reduce proteinuria to a greater extent than monotherapy, the risk of renal composite end point (dialysis, doubling of serum creatinine, and death) was actually increased.…”

Section: Introductionmentioning

confidence: 99%

Mineralocorticoid Receptor Antagonist for Renal Protection

King-Wing

Szeto

2012

Renal Failure

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The renin-angiotensin system (RAS) plays an important role in the pathophysiology of cardiovascular and renal diseases. In chronic kidney disease (CKD), blockade of RAS by angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) has been shown to reduce proteinuria and retard the progression of renal function deterioration. However, aldosterone, another key hormone of the RAS, is not directly targeted by ACEI or ARB. Hyperaldosteronism, apart from promoting sodium and fluid retention, causes inflammation and fibrosis in the heart and kidney. Studies have shown that although plasma aldosterone level shows an initial decrease following ACEI or ARB treatment, it returns to pretreatment level or even increases paradoxically after prolonged treatment. This "aldosterone breakthrough" forms the basis of adding mineralocorticoid receptor (MR) antagonist on top of ACEI or ARB for renal protection. New insights into the pathophysiological role of aldosterone in CKD further expands its potential indications, and there was a growing body of evidence in the past 10 years, which showed a substantial antiproteinuric effect and possibly a considerable renoprotective effect of MR antagonist. Since aldosterone does not act on the efferent glomerular arteriole and has no effect on intraglomerular hemodynamics, the very fact that MR antagonist ameliorates proteinuria sheds light on the physiology of glomerular permeability barrier. This review summarizes the data regarding the theoretical benefit as well as clinical use of MR antagonist in renal diseases.

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Combination Therapy With an Angiotensin Receptor Blocker and an ACE Inhibitor in Proteinuric Renal Disease: A Systematic Review of the Efficacy and Safety Data

Cited by 219 publications

References 47 publications

Implementation of a CKD Checklist for Primary Care Providers

Implementation of a CKD Checklist for Primary Care Providers

2016 European Society of Hypertension guidelines for the management of high blood pressure in children and adolescents

Mineralocorticoid Receptor Antagonist for Renal Protection

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