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Comparative Study
. 2012 Mar;55(3):566-78.
doi: 10.1007/s00125-011-2398-8. Epub 2011 Dec 22.

Reno-protective effects of renin-angiotensin system blockade in type 2 diabetic patients: a systematic review and network meta-analysis

P Vejakama  1 , A Thakkinstian, D Lertrattananon, A Ingsathit, C Ngarmukos, J Attia
Affiliations
Comparative Study

Reno-protective effects of renin-angiotensin system blockade in type 2 diabetic patients: a systematic review and network meta-analysis

P Vejakama et al. Diabetologia. 2012 Mar.

Abstract

Aims/hypothesis: This meta-analysis aimed to compare the renal outcomes between ACE inhibitor (ACEI)/angiotensin II receptor blocker (ARB) and other antihypertensive drugs or placebo in type 2 diabetes.

Methods: Publications were identified from Medline and Embase up to July 2011. Only randomised controlled trials comparing ACEI/ARB monotherapy with other active drugs or placebo were eligible. The outcome of end-stage renal disease, doubling of serum creatinine, microvascular complications, microalbuminuria, macroalbuminuria and albuminuria regression were extracted. Risk ratios were pooled using a random-effects model if heterogeneity was present; a fixed-effects model was used in the absence of heterogeneity.

Results: Of 673 studies identified, 28 were eligible (n = 13-4,912). In direct meta-analysis, ACEI/ARB had significantly lower risk of serum creatinine doubling (pooled RR = 0.66 [95% CI 0.52, 0.83]), macroalbuminuria (pooled RR = 0.70 [95% CI 0.50, 1.00]) and albuminuria regression (pooled RR 1.16 [95% CI 1.00, 1.39]) than other antihypertensive drugs, mainly calcium channel blockers (CCBs). Although the risks of end-stage renal disease and microalbuminuria were lower in the ACEI/ARB group (pooled RR 0.82 [95% CI 0.64, 1.05] and 0.84 [95% CI 0.61, 1.15], respectively), the differences were not statistically significant. The ACEI/ARB benefit over placebo was significant for all outcomes except microalbuminuria. A network meta-analysis detected significant treatment effects across all outcomes for both active drugs and placebo comparisons.

Conclusions/interpretation: Our review suggests a consistent reno-protective effect of ACEI/ARB over other antihypertensive drugs, mainly CCBs, and placebo in type 2 diabetes. The lack of any differences in BP decrease between ACEI/ARB and active comparators suggest this benefit is not due simply to the antihypertensive effect.

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Figures

Fig. 1
Fig. 1
Flow of study selection
Fig. 2
Fig. 2
Forest plots of treatment effects between ACEIs and other active drugs: (a) ESRD; (b) doubling of serum creatinine; (c) major microvascular complications; (d) macroalbuminuria; (e) microalbuminuria; and (f) albuminuria regression
Fig. 2
Fig. 2
Forest plots of treatment effects between ACEIs and other active drugs: (a) ESRD; (b) doubling of serum creatinine; (c) major microvascular complications; (d) macroalbuminuria; (e) microalbuminuria; and (f) albuminuria regression
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Comment in

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