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Meta-Analysis
. 2014 Jun 23;2014(6):CD009120.
doi: 10.1002/14651858.CD009120.pub2.

Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers for preserving residual kidney function in peritoneal dialysis patients

Ling Zhang  1 , Xiaoxi Zeng, Ping Fu, Hong Mei Wu
Affiliations
Meta-Analysis

Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers for preserving residual kidney function in peritoneal dialysis patients

Ling Zhang et al. Cochrane Database Syst Rev. .

Abstract

Background: Angiotensin-converting enzyme inhibitors (ACEis) and angiotensin receptor blockers (ARBs) are widely used in peritoneal dialysis (PD) patients, yet controversy exists about their impact on residual kidney function.

Objectives: This review aimed to evaluate the benefits and harms of ACEis and ARBs for preserving residual kidney function in PD patients.

Search methods: The Cochrane Renal Group's specialised register, Cochrane Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE (OvidSP interface), Chinese Biomedical Literature Database (CBM), China National Knowledge Infrastructure (CNKI) and other resources were searched by applying a prespecified comprehensive search strategy. Date of last search: 01 May 2014.

Selection criteria: Randomised controlled trials (RCTs) and quasi-RCTs comparing ACEis or ARBs with placebo, other antihypertensive drugs or each other in PD patients were included.

Data collection and analysis: Screening, selection, data extraction and quality assessments for each retrieved article were carried out by two authors using standardised forms. Authors were contacted when published data were incomplete. Statistical analyses were performed using the random effects model and results expressed as risk ratio (RR) with 95% confidence intervals (CI). Heterogeneity among studies was explored using the Cochran Q statistic and the I² test, subgroup analyses and random effects meta-regression.

Main results: Six open-label studies (257 patients) were identified. One study compared ACEi with other antihypertensive drugs, three compared ARBs with other antihypertensive drugs, and two studies compared an ARB with an ACEi. Long-term use (≥ 12 months) of an ARB showed significantly benefit of preserving residual kidney function in continuous ambulatory PD (CAPD) patients (MD 1.11 mL/min/1.73 m², 95% CI 0.38 to 1.83), although there was no significant benefit when an ARB were used short-term (≤ six months). One study showed that compared with other antihypertensive drugs, long-term use (12 months) of the ACEi ramipril showed a significant reduction in the decline of residual kidney function in patients on CAPD (MD -0.93 mL/min/1.73m², 95% CI -0.75 to -0.11), and delayed the progression to complete anuria (RR 0.64, 95% CI 0.41 to 0.99). There was no significant difference in serum potassium, urinary protein excretion, Kt/V, weekly creatinine clearance and blood pressure for ARBs versus other antihypertensive drugs. Compared with other antihypertensive drugs, ramipril showed no difference in mortality and cardiovascular events. Compared with an ACEi, ARBs did not show any difference in residual kidney function.The selection bias assessment was low in four studies and unclear in two. Five studies were open-label; however the primary outcome (residual kidney function) was obtained objectively from laboratory tests, and were not likely to be influenced by the lack of blinding. Reporting bias was unclear in all six studies.

Authors' conclusions: Compared with other antihypertensive drugs, long-term use (≥ 12 months) of ACEis or ARBs showed additional benefits of preserving residual kidney function in CAPD patients. There was no significant difference on residual kidney function preservation between ARBs and ACEis. However, limited by the small number of RCTs enrolling small number of participants, there is currently insufficient evidence to support the use of an ACEi or an ARB as first line antihypertensive therapy in PD patients.

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Conflict of interest statement

  1. Ling Zhang: none known

  2. Xiaoxi Zeng: none known

  3. Ping Fu: none known

  4. Hong Mei Wu: none known

Figures

1
1
Study flow diagram.
2
2
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
3
3
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
1.1
1.1. Analysis
Comparison 1 ARBs versus other antihypertensive drugs, Outcome 1 Residual kidney function [mL/min/1.73 m²].
1.2
1.2. Analysis
Comparison 1 ARBs versus other antihypertensive drugs, Outcome 2 Urinary protein excretion.
1.3
1.3. Analysis
Comparison 1 ARBs versus other antihypertensive drugs, Outcome 3 Kt/V.
1.4
1.4. Analysis
Comparison 1 ARBs versus other antihypertensive drugs, Outcome 4 Weekly creatinine clearance [mL/wk/1.73 m²].
1.5
1.5. Analysis
Comparison 1 ARBs versus other antihypertensive drugs, Outcome 5 Systolic BP.
1.6
1.6. Analysis
Comparison 1 ARBs versus other antihypertensive drugs, Outcome 6 Diastolic BP.
1.7
1.7. Analysis
Comparison 1 ARBs versus other antihypertensive drugs, Outcome 7 Peritonitis.
1.8
1.8. Analysis
Comparison 1 ARBs versus other antihypertensive drugs, Outcome 8 Serum potassium.
2.1
2.1. Analysis
Comparison 2 ACEis versus other antihypertensive drugs, Outcome 1 Change in residual kidney function [mL/min/1.73 m²].
2.2
2.2. Analysis
Comparison 2 ACEis versus other antihypertensive drugs, Outcome 2 All‐cause mortality.
2.3
2.3. Analysis
Comparison 2 ACEis versus other antihypertensive drugs, Outcome 3 Cardiovascular events.
2.4
2.4. Analysis
Comparison 2 ACEis versus other antihypertensive drugs, Outcome 4 Anuria.
2.5
2.5. Analysis
Comparison 2 ACEis versus other antihypertensive drugs, Outcome 5 Peritonitis.
3.1
3.1. Analysis
Comparison 3 ARBs versus ACEis, Outcome 1 Residual kidney function [mL/min/1.73 m²].
3.2
3.2. Analysis
Comparison 3 ARBs versus ACEis, Outcome 2 Cardiovascular events (nonfatal).
3.3
3.3. Analysis
Comparison 3 ARBs versus ACEis, Outcome 3 Anuria.
3.4
3.4. Analysis
Comparison 3 ARBs versus ACEis, Outcome 4 Systolic BP.
3.5
3.5. Analysis
Comparison 3 ARBs versus ACEis, Outcome 5 Diastolic BP.
3.6
3.6. Analysis
Comparison 3 ARBs versus ACEis, Outcome 6 Peritonitis.
3.7
3.7. Analysis
Comparison 3 ARBs versus ACEis, Outcome 7 Cough.
3.8
3.8. Analysis
Comparison 3 ARBs versus ACEis, Outcome 8 Serum potassium.
3.9
3.9. Analysis
Comparison 3 ARBs versus ACEis, Outcome 9 Hyperkalaemia.
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References

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