Comparison of the Effects of Angiotensin Receptor Antagonist, Angiotensin Converting Enzyme Inhibitor, and their Combination on Regression of Left Ventricular Hypertrophy of Diabetes Type 2 Patients on Recent Onset Hemodialysis Therapy

Abstract

Left ventricular hypertrophy (LVH) is frequently found at the initiation of dialysis therapy of diabetic and hypertensive patients, and is highly predictive of future cardiac morbidity and mortality. In patients with hypertension and LVH, both an angiotensin converting enzyme (ACE) inhibitor and an angiotensin type 1 receptor (AT1) antagonist regress LVH. However, it remains controversial whether dual blockade of the renin-angiotensin system will regress LVH in these patients using a combination of ACE inhibitor and AT1 antagonist. Thirty-three type II diabetic patients with end-stage renal disease who had just entered into hemodialysis therapy and were diagnosed as having LVH evaluated by echocardiography were selected from three dialysis units staffed by the faculty of Saitama Medical School, Saitama, Japan between 1999 and 2001. The study was carried out for 1 year. All patients were assigned randomly to three groups with equal number: group I, an ACE inhibitor, enalapril 10 mg daily; group II, an AT1 antagonist, losartan 100 mg daily; group III, combination of enalapril 10 mg and losartan 100 mg daily. All antihypertensive drugs were given 30 min after the cessation of dialysis therapy. LVH was evaluated by echocardiography before the start of administration of drugs, at 6 months and 12 months after the start of drug therapy. Systolic blood pressure levels less than 140 mmHg were the target for the three groups. Using repeated measures analysis of variance, applied to those with four echocardiograms, there were progressive decreases over time in left ventricular mass index, posterior wall thickness and interventricular septum thickness. There were no significant differences in regression of LVH as well as blood pressure control between enalapril and losartan groups; however, dual blockade induced an additional 28% reduction in left ventricular mass index compared with any type of monotherapy. Both ACE inhibitors and AT1 antagonists benefit the regression of LVH in diabetic patients who start dialysis therapy. Moreover, combination therapy with ACE inhibitors and AT1 antagonists would provide more beneficial effects on LVH in these patients than monotherapy.

Is left ventricular hypertrophy a modifiable risk factor in end-stage renal disease

“…Although a better response with angiotensin blockers compared to converting enzymes was not observed in another small trial of 33 incident, diabetic hemodialysis patients randomized to enalapril 10 mg daily, losartan 100 mg daily or combination therapy, there was a blood pressure independent benefit of more complete angiotensin blockade. At 1 year, LVH progressively decreased in all 3 groups, but there was an additional 28% reduction in the dual therapy group (P<0.05) 70 despite similar blood pressure reduction. A 3 rd small trial compared imadpril (2.5 mg daily) with placebo in 30 hemodialysis patients.…”

Medication changes based on echocardiography in dialysis patients

“…Echocardiogram findings such as LV systolic dysfunction, 5 LVH 6 and valvular calcification 7 are associated with increased mortality in dialysis patients. Intervention with medications has been shown to slow down the progression or regress the pathological echocardiogram findings (such as ACEI or ARB for LVH 8 and sevelamer for valvular calcification 9 ). However, to date, there are no studies that show improved mortality from these medications in dialysis patients with these specific echocardiogram findings (except carvedilol for dilated cardiomyopathy in a single study 10 ).…”

Renal and Cardiovascular Effects of Angiotensin-Converting Enzyme Inhibitor Plus Angiotensin II Receptor Antagonist Therapy in Children With Proteinuria

“…For adult hypertensive human patients, Devereux et al 25 reported reduction of the LVM after 12 and 24 months of treatment with losartan. Suzuki et al 26 reported that, for diabetic adults with end-stage renal disease undergoing hemodialysis, combined therapy with ACE inhibitors and AT 1 receptor antagonists was more effective in reducing the LVM after 6 and 12 months of treatment than was single therapy with ACE inhibitors or AT 1 receptor antagonists alone. It is noteworthy that the experimental studies with rats suggested that the heart mass reduction could become evident much earlier than commonly described, which supports our observation.…”