title: Renin-Angiotensin System Inhibitors and Kidney and Cardiovascular Outcomes in Patients With CKD: A Bayesian Network Meta-analysis of Randomized Clinical Trials.
abstract: BACKGROUND
  There is much uncertainty regarding the relative effects of angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs) in populations with chronic kidney disease (CKD).
  
  
  METHODS
  Systematic review and Bayesian network meta-analysis.
  
  
  METHODS
  Patients with CKD treated with renin-angiotensin system (RAS) inhibitors.
  
  
  METHODS
  Randomized trials in patients with CKD treated with RAS inhibitors.
  
  
  METHODS
  ACE inhibitors and ARBs compared to each other and to placebo and active controls.
  
  
  RESULTS
  Primary outcome was kidney failure; secondary outcomes were major cardiovascular events, all-cause death.
  
  
  RESULTS
  119 randomized controlled trials (n = 64,768) were included. ACE inhibitors and ARBs reduced the odds of kidney failure by 39% and 30% (ORs of 0.61 [95% credible interval, 0.47-0.79] and 0.70 [95% credible interval, 0.52-0.89]), respectively, compared to placebo, and by 35% and 25% (ORs of 0.65 [95% credible interval, 0.51-0.80] and 0.75 [95% credible interval, 0.54-0.97]), respectively, compared with other active controls, whereas other active controls did not show evidence of a significant effect on kidney failure. Both ACE inhibitors and ARBs produced odds reductions for major cardiovascular events (ORs of 0.82 [95% credible interval, 0.71-0.92] and 0.76 [95% credible interval, 0.62-0.89], respectively) versus placebo. Comparisons did not show significant effects on risk for cardiovascular death. ACE inhibitors but not ARBs significantly reduced the odds of all-cause death versus active controls (OR, 0.72; 95% credible interval, 0.53-0.92). Compared with ARBs, ACE inhibitors were consistently associated with higher probabilities of reducing kidney failure, cardiovascular death, or all-cause death.
  
  
  CONCLUSIONS
  Trials with RAS inhibitor therapy were included; trials with direct comparisons of other active controls with placebo were not included.
  
  
  CONCLUSIONS
  Use of ACE inhibitors or ARBs in people with CKD reduces the risk for kidney failure and cardiovascular events. ACE inhibitors also reduced the risk for all-cause mortality and were possibly superior to ARBs for kidney failure, cardiovascular death, and all-cause mortality in patients with CKD, suggesting that they could be the first choice for treatment in this population.
authors.affiliation: Renal Division, Peking University First Hospital; Peking University Institute of Nephrology; Key Laboratory of Renal Disease, Ministry of Health of China; Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Peking, China.
authors.forename: Xinfang
authors.initials: X
authors.lastname: Xie
authors.affiliation: Renal Division, Peking University First Hospital; Peking University Institute of Nephrology; Key Laboratory of Renal Disease, Ministry of Health of China; Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Peking, China.
authors.forename: Youxia
authors.initials: Y
authors.lastname: Liu
authors.affiliation: The George Institute for Global Health, the University of Sydney, Sydney, Australia.
authors.forename: Vlado
authors.initials: V
authors.lastname: Perkovic
authors.affiliation: Department of Nephrology, Affiliated Hospital of Weifang Medical College, Weifang, Shandong, China.
authors.forename: Xiangling
authors.initials: X
authors.lastname: Li
authors.affiliation: The George Institute for Global Health, the University of Sydney, Sydney, Australia.
authors.forename: Toshiharu
authors.initials: T
authors.lastname: Ninomiya
authors.affiliation: Renal Division, Peking University First Hospital; Peking University Institute of Nephrology; Key Laboratory of Renal Disease, Ministry of Health of China; Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Peking, China.
authors.forename: Wanyin
authors.initials: W
authors.lastname: Hou
authors.affiliation: Renal Division, Peking University First Hospital; Peking University Institute of Nephrology; Key Laboratory of Renal Disease, Ministry of Health of China; Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Peking, China.
authors.forename: Na
authors.initials: N
authors.lastname: Zhao
authors.affiliation: Renal Division, Peking University First Hospital; Peking University Institute of Nephrology; Key Laboratory of Renal Disease, Ministry of Health of China; Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Peking, China.
authors.forename: Lijun
authors.initials: L
authors.lastname: Liu
authors.affiliation: Renal Division, Peking University First Hospital; Peking University Institute of Nephrology; Key Laboratory of Renal Disease, Ministry of Health of China; Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Peking, China; The George Institute for Global Health, the University of Sydney, Sydney, Australia. Electronic address: jichenglv75@gmail.com.
authors.forename: Jicheng
authors.initials: J
authors.lastname: Lv
authors.affiliation: Renal Division, Peking University First Hospital; Peking University Institute of Nephrology; Key Laboratory of Renal Disease, Ministry of Health of China; Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Peking, China. Electronic address: hongzh@bjmu.edu.cn.
authors.forename: Hong
authors.initials: H
authors.lastname: Zhang
authors.affiliation: Renal Division, Peking University First Hospital; Peking University Institute of Nephrology; Key Laboratory of Renal Disease, Ministry of Health of China; Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Peking, China.
authors.forename: Haiyan
authors.initials: H
authors.lastname: Wang
mesh_terms: D057911:Angiotensin Receptor Antagonists / Q000627:therapeutic use*; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000627:therapeutic use*; D001499:Bayes Theorem; D002318:Cardiovascular Diseases / Q000453:epidemiology* / Q000401:mortality; D006801:Humans; D007676:Kidney Failure, Chronic / Q000453:epidemiology*; D016032:Randomized Controlled Trials as Topic; D051436:Renal Insufficiency, Chronic / Q000188:drug therapy*; D012084:Renin-Angiotensin System
chemical_list: D057911:Angiotensin Receptor Antagonists; D000806:Angiotensin-Converting Enzyme Inhibitors
keywords: Angiotensin-converting enzyme (ACE) inhibitor; Bayesian network meta-analysis; all-cause death; angiotensin II receptor blocker (ARB); blood pressure (BP); cardiovascular events; chronic kidney disease (CKD); comparative effectiveness; hypertension; kidney failure; mortality; renal disease progression; renin angiotensin system (RAS) inhibition