Angiotensin-Converting Enzyme Inhibitors and Angiotensin Receptor Blockers in Peritoneal Dialysis: Systematic Review and Meta-Analysis of Randomized Controlled Trials

Abstract

Background Angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) are widely used in clinical practice. The safety and efficacy of these agents in peritoneal dialysis (PD) patients are unclear. Objectives We conducted a systematic review to study the safety and efficacy of ACEI and ARB use in PD patients. Primary outcome measures were mortality and cardiovascular (CV) events; secondary outcome measures were renal function, proteinuria, hyperkalemia, and erythropoietin requirement at 3 months. Methods We searched Medline, EMBASE, Cochrane Central Register of Controlled Trials, trial registry Web sites, reference lists of eligible and review articles, as well as abstracts from the American Society of Nephrology and Canadian Society of Nephrology meetings. To be eligible, studies had to be randomized controlled trials that allocated PD patients to ACEI and ARB use or to placebo or other antihypertensive medications, included adult patients, and reported on at least one of the outcome measures. Results 418 citations were identified. Four met the eligibility criteria. Three examined CV events and mortality, of which two studies did not have any events. The third showed no statistically significant difference between control and treatment groups in either CV events or mortality: odds ratio 1.56 [95% confidence interval (CI) 0.24 – 10.05] for mortality and odds ratio 1.00 (95% CI 0.19 – 5.40) for CV events. Two studies reported renal function at 12 months and the weighted mean difference was 0.91 mL/minute/1.73 m2 (95% CI 0.14 – 1.68), favoring ACEI and ARB use. Conclusions In PD patients, evidence for the use of ACEIs and ARBs for reduction of mortality and CV events is lacking. Limited data suggest that they slow the loss of residual renal function.

Assessment of the effect of angiotensin-converting enzyme inhibitors and angiotensin receptor blockers in peritoneal dialysis patients: a systematic review and meta-analysis on clinical trials

“…Our results agree with those of previous reported SRs [25,26] that demonstrated the renoprotective effects of RASIs in PD patients. RCTs included in previous SRs overlapped with those in our SR.…”

“…The previous SR and CPG search yielded two SRs [25,26] which contained four [10,11,15,27] and six [10,[15][16][17][18]20] RCTs in each, with two [10,15] duplicated. We thus identified eight articles from this step.…”

Controversies in Timing of Dialysis Initiation and the Role of Race and Demographics

“…Holley et al (36) reported that race does not affect the rate of loss of renal function, but the study included only 25 nonwhite patients. In addition to race/ethnicity and gender (37,38), future studies should include as many key factors that may affect the rate of loss of residual renal function such as the type of renal replacement (39,40), BMI (38,41), arterial pressure (41)(42)(43)(44), use of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (37,45,46), diuresis (41,(47)(48)(49), protein intake (42,50,51), diabetes (37,38,50,(52)(53)(54)(55), cardiovascular comorbidity (37,38,52,54,56), and others. Additional studies should also be pursued to determine the potential impact of reduced access to care and whether late initiation of dialysis results in adverse clinical and economic outcomes among different ESRD patient groups in the United States.…”

Primary prevention of cardiovascular disease events with angiotensin-converting enzyme inhibitors and angiotensin receptor blockers in patients with autosomal dominant polycystic kidney disease on dialysis—a nationwide cohort study

“…In addition to fluid and sodium overload, dialysis patients are found to have increased sympathetic activity and abnormal response to RAAS, both of them result in higher incidence of hypertension and LVH. Although angiotensin-converting enzymes inhibitor (ACEI) and angiotensin II receptor blocker (ARB) have been shown to reduce CVD morbidity and mortality in the general population and high risk subjects [20][21][22], their protective effect in ESRD patients under dialysis remained uncertain [23]. Our previous study revealed that the overall mortality was significantly greater in patients who did not use an ACEI/ARB in ESRD patients on dialysis in a nationwide cohort [18].…”