Effects of angiotensin-converting enzyme inhibitors and angiotensin receptor blockers on cardiovascular events and residual renal function in dialysis patients: a meta-analysis of randomised controlled trials

Abstract

BackgroundThe role of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) reducing risk of cardiovascular events (CVEs) and preserving kidney function in patients with chronic kidney disease is well-documented. However, the efficacy and safety of these agents in dialysis patients is still a controversial issue.MethodsWe systematically searched MEDLINE, Embase, Cochrane Library and Wanfang for randomized trials. The relative risk (RR) reductions were calculated with a random-effects model. Major cardiovascular events, changes in GFR and drug-related adverse events were analyzed.ResultsEleven trials included 1856 participants who were receiving dialysis therapy. Compared with placebo or other active agents groups, ARB therapy reduced the risk of heart failure events by 33% (RR 0.67, 95% CI 0.47 to 0.93) with similar decrement in blood pressure in dialysis patients. Indirect comparison suggested that fewer cardiovascular events happened during treatment with ARB (0.77, 0.63 to 0.94). The results indicated no significant differences between the two treatment regimens with regard to frequency of myocardial infarction (1.0, 0.45 to 2.22), stroke (1.16, 0.69 to 1.96), cardiovascular death (0.89, 0.64 to 1.26) and all-cause mortality (0.94, 0.75 to 1.17). Five studies reported the renoprotective effect and revealed that ACEI/ARB therapy significantly slowed the rate of decline in both residual renal function (MD 0.93 mL/min/1.73 m2, 0.38 to 1.47 mL/min/1.73 m2) and urine volume (MD 167 ml, 95% CI 21 ml to 357 ml). No difference in drug-related adverse events was observed in both treatment groups.ConclusionsThis study demonstrates that ACE-Is/ARBs therapy decreases the loss of residual renal function, mainly for patients with peritoneal dialysis. Overall, ACE-Is and ARBs do not reduce cardiovascular events in dialysis patients, however, treatment with ARB seems to reduce cardiovascular events including heart failure. ACE-Is and ARBs do not induce an extra risk of side effects.Electronic supplementary materialThe online version of this article (doi:10.1186/s12882-017-0605-7) contains supplementary material, which is available to authorized users.

Hemodialysis‐induced cardiovascular disease

“…While RAAS blockade raises concerns of hypotension and hyperkalemia, these side effects may be outweighed by potential increased survival and cardiac function. Combination ARB and ACEI therapy appears to decrease the loss of residual renal function in patients on PD patients . There is no evidence that ARB and ACEI treatment differs with regard to myocardial infarction, stroke, cardiovascular death, and all‐cause mortality .…”

“…Combination ARB and ACEI therapy appears to decrease the loss of residual renal function in patients on PD patients. 100 There is no evidence that ARB and ACEI treatment differs with regard to myocardial infarction, stroke, cardiovascular death, and all-cause mortality. 100 In an earlier meta-analysis, ACEI and ARB treatment individually reduced LV mass in HD patients, but were not associated with reduction of cardiovascular events.…”

“…100 There is no evidence that ARB and ACEI treatment differs with regard to myocardial infarction, stroke, cardiovascular death, and all-cause mortality. 100 In an earlier meta-analysis, ACEI and ARB treatment individually reduced LV mass in HD patients, but were not associated with reduction of cardiovascular events. 101 More evidence is needed to definitively determine the utility of ACEI and ARBS in HD patients.…”

The importance of residual kidney function in haemodialysis patients

“…Blockade of the renin‐angiotensin system with angiotensin‐converting enzyme inhibitors and/or angiotensin receptor blockers has been demonstrated in several randomized controlled trials to help preserve RKF in PD patients . However, while there is some observational evidence that the use of these agents is associated with preservation of RKF in HD patients, the only prospective randomized controlled trial performed in HD patients found that irbesartan treatment for 1 year did not affect the decline in GFR or urine volume …”

Possible Association of Tremors and Dysarthria with Losartan Use: A Case Report

“…Because of this, there are a plethora of antihypertensives available to physicians. First line drugs in management include angiotensinconverting enzyme inhibitors (ACEi) and angiotensin receptor blockers (ARBs), especially indicated for diabetic patients due to their renoprotective effects [3][4]. However, sometimes due to the adverse effects of these medications, as can be witnessed with other medications, their use is limited.…”