Effect of acei on kidney
Pro Research Analysisby 
Searched over 200M research papers
Effects of ACE Inhibitors on Kidney Health
Introduction to ACE Inhibitors and Kidney Health
Angiotensin-converting enzyme inhibitors (ACEIs) are commonly prescribed medications for managing hypertension and chronic kidney disease (CKD). They work by inhibiting the conversion of angiotensin I to angiotensin II, a potent vasoconstrictor, thereby reducing blood pressure and proteinuria, and offering protective effects on the kidneys.
Benefits of ACE Inhibitors in Chronic Kidney Disease
Reduction in Kidney Events and Cardiovascular Outcomes
ACEIs 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 demonstrated that ACEI monotherapy decreased the odds of kidney events by 46% and cardiovascular events by 27% compared to placebo 1. This protective effect extends to reducing the risk of end-stage kidney disease (ESKD) and delaying the progression of CKD.
Impact on Diabetic Kidney Disease
In patients with diabetic kidney disease (DKD), ACEIs are effective in reducing the progression of renal disease. A systematic review found that full-dose ACEIs significantly reduced the risk of all-cause mortality compared to placebo, although the benefits were not as pronounced when compared directly with angiotensin II receptor blockers (ARBs) 2. This suggests that ACEIs are particularly beneficial when used at their maximum tolerable doses.
ACE Inhibitors in Acute Kidney Injury
Lower Mortality and Recurrent Adverse Kidney Events
For patients experiencing acute kidney injury (AKI), continued use of ACEIs has been associated with lower risks of all-cause mortality and recurrent AKI. A meta-analysis involving 70,801 patients found that ACEI users had a significantly lower mortality rate and reduced risk of recurrent adverse kidney events compared to non-users 3. However, the risk of hyperkalemia was higher in ACEI users, necessitating careful monitoring.
ACE Inhibitors in Kidney Transplant Recipients
Limited Evidence and Potential Risks
The benefits of ACEIs observed in non-transplant populations may not extend to kidney transplant recipients. A multicenter randomized controlled trial indicated that ACEIs did not significantly improve renal outcomes in transplant recipients and were associated with a decrease in glomerular filtration rate (GFR) and an increase in hyperkalemia 4. This suggests that while ACEIs are beneficial for CKD patients, their use in transplant recipients should be carefully considered.
Combination Therapy with ARBs
Efficacy and Safety Concerns
Combining ACEIs with ARBs has been explored to enhance renal protection. A meta-analysis of 53 randomized controlled trials found that combination therapy was more effective than low-dose monotherapy in reducing urine albumin and protein excretion, but it also increased the risk of hyperkalemia and hypotension 5. Therefore, while combination therapy may offer additional benefits in reducing proteinuria, it comes with increased safety concerns.
Conclusion
ACE inhibitors play a crucial role in managing chronic kidney disease by reducing the risk of kidney events, cardiovascular outcomes, and mortality. They are particularly effective in non-dialysis CKD stages 3-5 and in patients with diabetic kidney disease when used at full doses. However, their benefits in kidney transplant recipients are less clear, and combination therapy with ARBs, while effective in reducing proteinuria, poses significant safety risks. Careful monitoring and individualized treatment plans are essential to maximize the benefits and minimize the risks associated with ACEI therapy.
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 CitedAngiotensin converting enzyme inhibitors and angiotensin II receptor antagonists for preventing the progression of diabetic kidney disease.
ACEi at maximum tolerable dose significantly reduce the risk of all-cause mortality in diabetic kidney disease patients, while both ACEi and AIIRA show similar benefits on renal outcomes.
Meta-AnalysisHighly CitedThe Impact of Angiotensin-Converting Enzyme Inhibitors or Angiotensin II Receptor Blockers on Clinical Outcomes of Acute Kidney Disease Patients: A Systematic Review and Meta-Analysis
Exposure to ACEi/ARB after acute kidney injury is associated with lower risks of all-cause mortality, recurrent AKI, and progression to chronic kidney disease.
Meta-AnalysisAngiotensin-Converting Enzyme Inhibitors—Beneficial Effects Seen in Many Patient Groups May Not Extend to Kidney Transplant Recipients
ACEi may not have the same beneficial effects on kidney transplant recipients as in nontransplant populations, potentially leading to reduced blood pressure and proteinuria.
RCTEfficacy and Safety of Angiotensin-Converting Enzyme Inhibitor in Combination with Angiotensin-Receptor Blocker in Chronic Kidney Disease Based on Dose: A Systematic Review and Meta-Analysis
ACEI in combination with ARB is effective in reducing urine albumin and protein excretion in chronic kidney disease patients, but may cause decreased GFR and increased hyperkalemia rates.
Meta-AnalysisMulticentre randomized controlled trial of angiotensin-converting enzyme inhibitor/angiotensin receptor blocker withdrawal in advanced renal disease: the STOP-ACEi trial
Discontinuing ACEi/ARB treatment can stabilize or improve renal function in patients with advanced progressive chronic kidney disease without increasing cardiovascular events.
RCT
Large Human TrialHighly CitedAngiotensin-converting enzyme inhibitors and angiotensin receptor blockers for preserving residual kidney function in peritoneal dialysis patients.
Long-term use of angiotensin receptor blockers (ARBs) significantly preserves residual kidney function in peritoneal dialysis patients, while short-term use of ARBs shows no significant benefit.
Meta-Analysis
Very Rigorous JournalEffect of combining ACE inhibition with aldosterone blockade on proteinuria and renal damage in experimental nephrosis.
Combining ACE inhibition with aldosterone blockade effectively reduces proteinuria and prevents renal damage in a rat model of chronic proteinuria-induced renal damage.
RCT
Animal Study
Rigorous JournalAntihypertensives for Kidney Transplant Recipients: Systematic Review and Meta-Analysis of Randomized Controlled Trials
Calcium channel blockers may be preferred as first-line agents for hypertensive kidney transplant recipients, reducing graft loss and improving glomerular filtration rate compared to angiotensin-converting enzyme inhibitors.
Meta-AnalysisHighly CitedEffects of withdrawing vs continuing renin-angiotensin blockers on incidence of acute kidney injury in patients with renal insufficiency undergoing cardiac catheterization: Results from the Angiotensin Converting Enzyme Inhibitor/Angiotensin Receptor Blocker and Contrast Induced Nephropathy in Patie
Holding ACEI/ARB prior to coronary angiography in patients with moderate renal insufficiency reduces contrast-induced acute kidney injury and post-procedural creatinine rise.
RCTRigorous JournalHighly Cited