Abstract
Background It is still debated whether the protective effects are different among the various classes of antihypertensive agents in patients with diabetic nephropathy. We undertook a systematic review and network meta-analysis to investigate the effectiveness of angiotensin converting enzyme inhibitors (ACEI), angiotensin II receptor blockers (ARB), or calcium channel blockers (CCB), compared with placebo on major clinical outcomes, defined as doubling of creatinine, requiring dialysis, or all-cause deaths. Methods We systematically searched PubMed, MEDLINE, and the Cochrane Library for trials published between 1970 and March, 2011. We included prospective randomized controlled trials assessing the effects of ACEI, ARB, or CCB on major outcomes compared with placebo or active control with different drug classes. Bayesian mixed treatment comparisons were used to calculate the odds ratio (OR) and 95% credible interval (CrI) to determine the relative effects of each treatment. Findings We identified 53 trials providing data for 27404 participants, including 997 doubling creatinine, 159 requiring dialysis, and 1672 deaths. Network meta-analysis showed that ACEI (OR, 0.64; 95% CrI, 0.34–0.97) reduced doubling of creatinine compared with placebo, whereas ARB (OR, 0.72; 95% CrI, 0.34–1.53) or CCB (OR, 1.16; 95% CrI, 0.47–3.00) did not show this protective effect. ACEI (OR, 0.68; 95% CrI, 0.38–1.05), ARB (OR, 0.71; 95% CrI, 0.44–1.14), and CCB (OR, 0.91; 95% CrI, 0.52–1.46) provided non-significant protective effects to prevent dialysis. On the other hand, all classes of drugs had no significant effect on reducing all-cause deaths. Interpretation ACEI represented the most effective class of drugs in preventing doubling of creatinine, and might have a role in reducing risk of dialysis or all-cause deaths. Thus, our findings support the use of ACEI as the first-line strategy for renal protection in patients with diabetic nephropathy. ARB and CCB were found to be less effective in this population.
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