A meta-analysis suggests that these drugs slow progression of stage 4 or 5 CKD.

ACE inhibitors or angiotensin­ receptor blockers (ARBs) are seldom initiated among patients with chronic kidney disease (CKD) stage 4 or 5, despite guideline recommendations for these agents as first-­line antihyperten­sive agents and to slow progression of CKD (NEJM JW Gen Med Dec 15 2017 and J Am Coll Cardiol 2018; 71: e127-­e248). In a patient-­level meta-­analysis of 18 randomised trials, researchers identified 1700 patients with stage 4 or 5 CKD (estimated glomerular filtration rate [eGFR], below 30 mL/minute/1.73 m²) to determine if initiating ACE inhibitors or ARBs affected progression to dialysis or death. Mean follow up was about three years.

Patients with CKD stage 4 or 5 (mean eGFR, 22 mL/minute/1.73 m²) who initia­ted ACE inhibitors or ARBs (vs placebo or other antihypertensive agents) were significantly less likely to progress to dialysis (12% vs 17% annually; number needed to treat, 20), but mortality was similar (about 3% annually). Adjustment for numerous relevant potential confoun­ders (including albuminuria and baseline blood pressure) did not affect these findings.

Comment: Unfortunately, these resear­chers were unable to assess adverse events such as hyperkalaemia or acute kidney injury. Nevertheless, the results are compelling and should encourage us to initiate these medications in patients with advanced CKD.

Daniel D. Dressler, MD, MSc, MHM, FACP, Professor of Medicine, Emory University School of Medicine, Atlanta, USA.

Ku E, et al. Angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers for advanced chronic kidney disease: a systematic review and retrospective individual participant-level meta-analysis of clinical trials. Ann Intern Med 2024; 177: 953-963.

This summary is taken from the following Journal Watch titles: General Medicine, Ambulatory Medicine, Hospital Medicine.