Evaluating the Options for Blood Pressure-Lowering in Adults With Diabetes and Kidney Disease | Journal Scan

Study Questions:

What are the comparative effects of all blood pressure-lowering agents in adults with diabetes and kidney disease?

Methods:

This was a network meta-analysis. Eligible patients were adults with diabetes and chronic kidney disease and who were treated in clinical trials that compared any orally administered blood pressure-lowering agent, alone or in combination, with a second blood pressure agent or combination, placebo, or control. Primary outcomes were all-cause mortality and end-stage kidney disease (need for dialysis or kidney transplantation). The authors ranked the comparative effects of all drugs against placebo with surface under the cumulative ranking (SUCRA) probabilities.

Results:

A total of 157 studies with data for 43,256 participants were available for network meta-analysis. Seven drug classes alone or in combination were compared with placebo or standard treatment – angiotensin-converting enzyme (ACE) inhibitors, angiotensin-receptor blockers (ARBs), aldosterone antagonists, beta-blockers, calcium-channel blockers, endothelin inhibitors, and renin inhibitors. No drug regimen was more effective than placebo for reducing all-cause mortality. End-stage renal disease was significantly less likely after dual treatment with an ARB and an ACE inhibitor (odds ratio [OR], 0.62; 95% confidence interval [CI], 0.43-0.90) and after ARB monotherapy (OR, 0.77; 95% CI, 0.65-0.92). The risks of drug-induced acute kidney injury and hyperkalemia were similar for all drugs, but point estimates suggested that combined ACE inhibitor and ARB treatment increased risk of these harms.

Conclusions:

Although combined ACE inhibitor and ARB treatment was the most effective strategy against end-stage kidney disease in this meta-analysis of adults with diabetes and kidney disease, no blood pressure-lowering strategy prolonged survival.

Perspective:

This is an interesting analysis that suggests blood pressure-lowering in adults with diabetes and kidney disease does not increase survival. Considering the limitations of meta-analysis, such findings should not dissuade providers from treating hypertension in this population. The analysis also draws support for ACE inhibitors and ARBs, alone or in combination, as an effective strategy for preventing end-stage renal disease. A strategy of dual ACE inhibitor and ARB treatment is controversial, but may be beneficial, provided there is careful surveillance for acute kidney injury and hyperkalemia.

Clinical Topics: Diabetes and Cardiometabolic Disease, Dyslipidemia, Prevention, Lipid Metabolism, Novel Agents, Hypertension

Keywords: Acute Kidney Injury, Adrenergic beta-Antagonists, Angiotensin Receptor Antagonists, Angiotensin-Converting Enzyme Inhibitors, Antihypertensive Agents, Blood Pressure, Calcium Channel Blockers, Diabetes Mellitus, Endothelins, Hyperkalemia, Hypertension, Kidney Failure, Chronic, Kidney Transplantation, Metabolic Syndrome X, Mineralocorticoid Receptor Antagonists, Primary Prevention, Renal Insufficiency, Chronic, Renal Dialysis, Renin


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