Giatras I, Lau J, Levey AS
Effects of ACE inhibitors on the progression of non-
diabetic renal disease
Am Soc Nephrol
J Am Soc Nephrol (abstract)
(Sep) 7:1318 1996
For about the past 15 years, studies, mostly in rats, have suggested that
progression of chronic renal disease to end-stage (ESRD) is independent of
the initial disease because glomerulosclerosis is mediated by glomerular
capillary hypertension. If so, ACE inhibitors, which selectively lower
glomerular pressure, should be most effective in inhibiting progression to
ESRD.
This abstract is a meta-analysis, which combines the results of a number of
smaller studies in order to achieve a larger, and perhaps more
representative, patient sample. The authors looked at 10 series comparing
the relative risk of progression to ESRD of non-diabetic patients treated
either with ACE inhibitors or other antihypertensives. They included
several unpublished series to prevent publication bias (negative results are
harder to publish than positive).
The combined series totalled 1594
patients, 806 on ACEI and 788 controls. 6.4% of the ACEI patients and 9.1%
of the controls reached ESRD during the observation period. While the
reported risk ratio was said not to be significant in any individual study,
the pooled risk ratio was 0.70 in the ACEI group compared to controls, p =
.03. There was no difference in mortality between the two groups. The
subjects taking ACEI had a greater mean fall in both systolic (9.4 mm Hg)
and diastolic (1.9 mm Hg).
Comment: This study confirms that ACEI can be effective in retarding
the progression
of chronic renal failure to ESRD. Whether they are superior to other anti-
hypertensives remains open. This study has the flaw of all meta-analyses:
conditions for the subjects were different and the control antihypertensive
regimens variable. Less ESRD in the ACEI group could be due to improved
glomerular hemodynamics or to better BP control. ACEI are useful, but can
cause hyperkalemia and require careful patient monitoring when used in renal
failure.
(Don Feinfeld MD, State University of New York at Stony Brook)
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Am Soc Nephrol
H: Drug therapy :
ACE inhibitors
CRF by problem area :
Progression