Chronic kidney disease ace inhibitor
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The Role of ACE Inhibitors in Managing Chronic Kidney Disease
Introduction to ACE Inhibitors and Chronic Kidney Disease
Chronic Kidney Disease (CKD) is a progressive condition characterized by the gradual loss of kidney function over time. Angiotensin-converting enzyme inhibitors (ACEIs) are commonly prescribed to manage CKD due to their ability to reduce blood pressure and provide renal protection. This article synthesizes recent research on the efficacy and safety of ACE inhibitors in patients with CKD, particularly those in non-dialysis stages 3-5.
Benefits of ACE Inhibitors in CKD
Kidney and Cardiovascular Outcomes
ACE inhibitors have been shown to significantly reduce the risk of kidney events, cardiovascular events, cardiovascular death, and all-cause mortality in patients with non-dialysis CKD stages 3-5. A network meta-analysis of 44 randomized clinical trials involving 42,319 patients found that ACEI monotherapy decreased the odds of kidney events by 46%, cardiovascular events by 27%, cardiovascular death by 27%, and all-cause death by 23% compared to placebo 1. These findings highlight the substantial protective effects of ACE inhibitors on both renal and cardiovascular outcomes.
Comparison with ARBs and Other Antihypertensive Drugs
When compared to angiotensin II receptor blockers (ARBs) and other antihypertensive drugs such as calcium channel blockers (CCBs) and β-blockers, ACE inhibitors consistently showed superior outcomes in preventing kidney events and reducing all-cause mortality 13. However, ARBs were found to be more effective than placebo in preventing kidney events, although they did not significantly lower the odds of cardiovascular events and all-cause death in diabetic kidney disease patients 1.
Safety Concerns and Adverse Effects
Hyperkalemia and Cough
Despite their benefits, ACE inhibitors are associated with several adverse effects, including hyperkalemia and cough. The odds of hyperkalemia were significantly higher with ACEI therapy compared to CCBs and placebo, with ACEIs having 3.81 times higher odds than CCBs 1. Additionally, ACE inhibitors increased the odds of cough compared to placebo and other antihypertensive drugs 1.
Renal Function and Discontinuation
A multicenter trial investigated the effects of discontinuing RAS inhibitors, including ACEIs, in patients with advanced CKD. The study found no significant difference in the long-term rate of decrease in estimated glomerular filtration rate (eGFR) between the discontinuation and continuation groups 2. This suggests that while ACE inhibitors are beneficial, their discontinuation in advanced CKD does not necessarily accelerate renal decline.
Optimizing ACE Inhibitor Therapy
Combination Therapy
Combining ACE inhibitors with ARBs has been explored to enhance therapeutic outcomes. Although combination therapy showed a further decrease in proteinuria, it also resulted in a small but significant increase in serum potassium levels 910. Therefore, while combination therapy may offer additional benefits, it should be reserved for high-risk patients and closely monitored for adverse effects.
Dietary and Pharmacological Considerations
The safety and efficacy of ACE inhibitors can be optimized by managing dietary sodium intake and using diuretics to mitigate adverse effects such as hyperkalemia and hypotension 58. This approach can enhance the renoprotective effects of ACE inhibitors while minimizing potential risks.
Conclusion
ACE inhibitors play a crucial role in managing CKD by significantly reducing the risk of kidney events, cardiovascular events, and all-cause mortality. However, their use is associated with adverse effects such as hyperkalemia and cough. Optimizing therapy through careful monitoring, dietary adjustments, and potential combination with other antihypertensive agents can maximize benefits while minimizing risks. Further research is needed to refine these strategies and ensure the best outcomes for CKD patients.
Sources and full results
Most relevant research papers on this topic
ACE Inhibitor Benefit to Kidney and Cardiovascular Outcomes for Patients with Non-Dialysis Chronic Kidney Disease Stages 3–5: A Network Meta-Analysis of Randomised Clinical Trials
ACE inhibitors significantly decrease the odds of kidney events, cardiovascular events, and all-cause death in non-dialysis chronic kidney disease stages 3-5 patients, while ARBs show no significant advantage.
Meta-Analysis
Highly CitedRenin-Angiotensin System Inhibition in Advanced Chronic Kidney Disease.
Discontinuing RAS inhibitors in patients with advanced chronic kidney disease did not significantly affect the long-term rate of decline in eGFR.
RCT
Large Human Trial
Rigorous JournalHighly CitedRenin-Angiotensin System Inhibitors and Kidney and Cardiovascular Outcomes in Patients With CKD: A Bayesian Network Meta-analysis of Randomized Clinical Trials.
ACE inhibitors and ARBs reduce kidney failure and cardiovascular events in patients with chronic kidney disease, with ACE inhibitors potentially being the first choice for treatment.
Meta-AnalysisHighly CitedEffect of ACE inhibitors in diabetic and nondiabetic chronic renal disease: a systematic overview of randomized placebo-controlled trials.
ACE inhibitors effectively slow the progression of chronic renal insufficiency across a wide range of disease causes and renal dysfunction.
Meta-AnalysisHighly CitedSafety of ACE inhibitor therapies in patients with chronic kidney disease
ACE inhibitors are effective in treating chronic kidney disease, but their side effects require better strategies to address safety concerns and reduce the risk of adverse effects.
Literature ReviewAngiotensin-Converting Enzyme Inhibitors and Progression of Nondiabetic Renal Disease
ACE inhibitors slow the progression of nondiabetic renal disease, but their effectiveness depends on patient characteristics and blood pressure.
Meta-AnalysisHighly CitedOptimizing ACE-inhibitor therapy for chronic kidney disease.
Benazepril is feasible and beneficial in patients with advanced chronic kidney disease, even in stage 4 disease.
Combination therapy with an angiotensin receptor blocker and an ACE inhibitor in proteinuric renal disease: a systematic review of the efficacy and safety data.
Combination therapy with an ACE inhibitor and an ARB is safe and significantly reduces proteinuria in patients with chronic proteinuric renal disease.
Systematic ReviewHighly CitedCombination therapy with ACE inhibitors and angiotensin II receptor blockers to halt progression of chronic renal disease: pathophysiology and indications.
Combination therapy with ACE inhibitors and angiotensin II receptor blockers may slow the progression of chronic renal disease and reduce hard end-points, but should be reserved for high-risk groups.
Highly Cited