Efficacy and Safety of Angiotensin-Converting Enzyme Inhibitors in Combination with Angiotensin-Receptor Blockers in Nondiabetic Chronic Kidney Disease: A Systematic Review and Meta-Analysis.

Abstract

It is unclear whether angiotensin-converting enzyme inhibitors (ACEIs) in combination with angiotensin-receptor blockers (ARBs) are superior to ACEIs or ARBs alone in the treatment of nondiabetic chronic kidney disease (CKD). The present meta-analysis was designed to assess the efficacy and safety of ACEIs in combination with ARBs in nondiabetic CKD. The PubMed, Embase, and Cochrane Library databases were searched to identify randomized controlled trials (RCTs) published prior to March 2020. A random-effects model was used to calculate the effect sizes of eligible studies. The present meta-analysis of 20 RCTs encompassing 1,398 patients with nondiabetic CKD demonstrated that ACEIs in combination with ARBs were superior to ACEIs or ARBs alone in reducing urine albumin excretion (SMD, -0.69; 95% CI, -1.13 to -0.25; P=0.002), urine protein excretion (SMD, -0.34; 95% CI, -0.46 to -0.23; P<0.001), and blood pressure (systolic blood pressure: WMD, -1.43; 95% CI, -2.42 to -0.44; P=0.005; diastolic blood pressure: WMD, -1.85; 95% CI, -2.67 to -1.04; P<0.001) without decreasing glomerular filtration rate (SMD, -0.07; 95% CI, -0.20 to 0.06; P=0.30) or increasing incidences of hyperkalaemia (RR, 1.70; 95% CI, 0.47 to 6.11; P=0.42) and hypotension (RR, 1.80; 95% CI, 0.67 to 4.86; P=0.25). Compared with ACEIs or ARBs alone, ACEIs in combination with ARBs are effective and safe in the treatment of nondiabetic CKD. ACEIs combined with ARBs may be a better choice to reduce proteinuria as long as they can be tolerated.