Cardiovascular benefits of treatment with angiotensin receptor blockers in patients with hypertension and chronic kidney disease: a systematic review and meta-analysis

Burnier M , S Lin , L Ruilope , G Bader , S Durg , D Lin , P Brunel

Abstract

Background: Guidelines recommend initiating antihypertensive treatment with an angiotensin II receptor blocker (ARB) or an angiotensin-converting enzyme inhibitor, either as monotherapy or in combination with existing treatments, as first-line therapy for patients with hypertension and chronic kidney disease (CKD).

Purpose: This study reviewed and analyzed the effect of ARB treatment on blood pressure (BP) related outcomes in patients with hypertension and CKD.

Methods: A literature review was performed in MEDLINE, EMBASE, and BIOSIS databases from the earliest available date to July 2017. Parallel-group, randomized controlled trials (≥8 weeks) that assessed the impact of ARBs on systolic/diastolic BP (SBP/DBP), glomerular filtration rate (GFR), serum creatinine (SCr), creatinine clearance (CrCl) or proteinuria were included in the analysis. Meta-analysis (post- versus pre-treatment) was conducted with R-statistical software (v3.4.1) using a meta-package. Mean difference (MD, generic inverse variance) with 95% confidence intervals (CIs) was used to pool data for an outcome in a single forest plot. The quality of included studies was evaluated by risk of bias assessment across the six items of the Cochrane instrument.

Results: Of the 411 records screened, 161 full-text articles were assessed for eligibility, and 20 studies were included in the analysis (15 evaluated ARBs as monotherapy, four evaluated ARBs in combination with other antihypertensives and one study evaluated ARBs both as mono- and combination therapy). ARB monotherapy for ≥8 weeks to <1 year demonstrated a significant (P<0.01) reduction in mean SBP (MD: −12.60; 95% CI, −18.53 to −6.67)/DBP (−6.52; −11.27 to −1.77). BP reduction was greater (P<0.01) with ARB monotherapy for ≥1-year SBP (−15.85; −21.38 to −10.31)/DBP (−11.62; −15.90 to −7.34). ARBs in combination with other antihypertensive treatments for ≥8 weeks to <1 year as well as for ≥1 year resulted in a significant (P<0.01) reduction in SBP/DBP (Figure). Moreover, ARB treatment demonstrated significant reduction (P<0.01) in proteinuria, without any significant changes in GFR, CrCl, or SCr levels. There was no significant (P=0.6485) impact of ARB treatment duration on SBP change (estimate: 0.0679; 95% CI, −0.2242 to 0.3601). No significant (P=0.5251) impact of SBP change on GFR change (estimate: 0.0677; 95% CI, −0.1411 to 0.2765) was observed. The overall risk of bias was judged to be low.

Conclusion: ARB treatment effectively lowered blood pressure and improved renal outcomes in patients with hypertension and CKD.

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