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Vendeville N, Lepage MA, Festa MC, Mavrakanas TA. Clinical Outcomes of Renin-Angiotensin Aldosterone Blockade in Patients with Advanced Chronic Kidney Disease: A Systematic Review and Meta-Analysis. Can J Cardiol 2024:S0828-282X(24)00192-2. [PMID: 38458564 DOI: 10.1016/j.cjca.2024.02.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 02/09/2024] [Accepted: 02/13/2024] [Indexed: 03/10/2024] Open
Abstract
BACKGROUND The cardiovascular and renal benefits of renin-angiotensin aldosterone system (RAAS) blockade are not well-established in patients with advanced CKD. We conducted a systematic review and meta-analysis to identify potential risks and benefits from RAAS blockade in patients with CKD stage 4-5. METHODS A Medline search from inception to November 2022 was conducted to identify randomized controlled trials (RCTs) in patients with CKD stage 4-5 (estimated GFR ≤ 30 mL/min/1.73m2) comparing RAAS blockade against placebo or alternative antihypertensive therapy. Different intervention strategies were assessed (RAAS use vs non-use, initiation vs placebo/alternative therapy or discontinuation vs continuation). The primary outcome was progression to end-stage kidney disease (ESKD). Secondary outcomes were all-cause mortality and major adverse cardiovascular events (MACE). The risk ratio (RR) was estimated using a random-effects model. RESULTS Nine RCTs (1,150 patients) were included. In RCTs, RAAS blockade was associated with a significant reduction in progression to ESKD: RR 0.84 (95% confidence interval [CI] 0.74 - 0.96; p = 0.01). There was no benefit from RAAS blockade on all-cause mortality or MACE: RR 1.02 (95% CI 0.63 - 1.65; p = 0.93) and RR 0.87 (95% CI 0.49- 1.57; p = 0.65), respectively. CONCLUSIONS RAAS blockade may be considered in selected patients with CKD stage 4-5 to delay progression to ESKD.
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Affiliation(s)
- Nicolas Vendeville
- University of British Columbia, Division of Nephrology; McGill University, Faculty of Medicine and Health Sciences.
| | | | | | - Thomas A Mavrakanas
- McGill University Health Centre, Department of Medicine, Division of Nephrology; Research Institute, McGill University Health Centre, Montreal, Quebec, Canada
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Pattanaprateep O, Ingsathit A, McEvoy M, Attia J, Thakkinstian A. Cost-Effectiveness Analysis of Renin-Angiotensin Aldosterone System Blockade in Progression of Chronic Kidney Disease. Value Health Reg Issues 2018; 15:155-60. [PMID: 29730248 DOI: 10.1016/j.vhri.2017.12.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Revised: 11/27/2017] [Accepted: 12/04/2017] [Indexed: 11/21/2022]
Abstract
OBJECTIVES To assess the cost effectiveness of renin-angiotensin aldosterone system (RAAS) blockade in the progression of chronic kidney disease using Thai clinical data in 2014. METHODS A Markov model for cost-effectiveness analysis was applied to estimate from a societal perspective the cost per quality-adjusted life-year (QALY) gained and the incremental cost-effectiveness ratio of RAAS versus non-RAAS used in preventing the progression of end-stage renal disease and death stratified by diabetic and nondiabetic patients. Input parameters related to clinical outcomes were obtained from a cohort study of treatment effectiveness, whereas costs were retrieved from the Ramathibodi Hospital electronic database in 2015 and the Health Intervention and Technology Assessment Program in Thailand. One-way analysis and probabilistic sensitivity analysis were performed to evaluate uncertainty surrounding model parameters. RESULTS From the model, using RAAS improved QALY from 2.41 to 3.16 years and from 2.37 to 3.20 years in diabetic and nondiabetic groups, respectively. The incremental cost-effectiveness ratios for these groups were 78,250 baht (US $2,353.39) and 66,674 baht (US $2,005.22), respectively. CONCLUSIONS Using RAAS in patients with chronic kidney disease improved QALY in both diabetic and nondiabetic patients and proved to be cost-effective.
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Kuo KL, Hung SC, Tseng WC, Liu JS, Lin MH, Hsu CC, Tarng DC. Dipyridamole decreases dialysis risk and improves survival in patients with pre-dialysis advanced chronic kidney disease. Oncotarget 2018; 9:5368-77. [PMID: 29435184 DOI: 10.18632/oncotarget.19850] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Accepted: 07/25/2017] [Indexed: 01/13/2023] Open
Abstract
Introduction Dipyridamole decreases proteinuria and improves renal function progression in patients with glomerular disease through its inhibition of platelet activation and enhanced nitric oxide expression. Few studies have evaluated the effects of dipyridamole on renal outcome or survival in CKD stage 5 patients who have not yet received dialysis (CKD 5 ND). Materials and Methods A prospective cohort study was conducted based on the Taiwan National Health Insurance Research Database. From January 1, 2000 to June 30, 2009, we enrolled 28,497 patients who had a serum creatinine > 6 mg/dL and a hematocrit < 28% and who were treated with erythropoiesis-stimulating agents (ESAs). All patients were further divided into two groups with or without dipyridamole use within 90 days after starting ESA therapy. Patient followed-up took place until dialysis, death before initiation of dialysis or December 31, 2009. The primary outcomes were long-term dialysis and death before initiating dialysis. Results The dipyridamole users and nonusers groups included 7,746 and 20,751 patients, respectively. We found that 20,152 patients (70.7%) required long-term dialysis and 5,697 patients (20.0%) died before a progression to end-stage renal disease required dialysis. After propensity score-matching, dipyridamole users were associated with lower risks for long-term dialysis (adjusted HR, 0.96; 95% CI, 0.93–0.99) and death (adjusted HR, 0.91; 95% CI, 0.85–0.97) compared with nonusers. Conclusions Dipyridamole exhibited a protective effect in reducing the risk for long-term dialysis and death among CKD 5 ND patients. Randomized studies are needed to validate this association.
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Sung PH, Chiang HJ, Lee MS, Chiang JY, Yip HK, Yang YH. Combined renin-angiotensin-aldosterone system blockade and statin therapy effectively reduces the risk of cerebrovascular accident in autosomal dominant polycystic kidney disease: a nationwide population-based cohort study. Oncotarget 2017; 8:61570-61582. [PMID: 28977886 PMCID: PMC5617446 DOI: 10.18632/oncotarget.18636] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Accepted: 05/22/2017] [Indexed: 12/14/2022] Open
Abstract
Fairly limited data reported the incidence and risk of cerebrovascular accident (CVA) in autosomal dominant polycystic kidney disease (ADPKD). Additionally, little is known regarding the therapeutic impact of renin-angiotensin-aldosterone system (RAAS) blockade and statin on reducing the occurrence of CVA in ADPKD. We utilized the data from Taiwan National Health Insurance Research Database (NHIRD) to perform a population-based cohort study (1997-2013). A total of 2,647 patients with ADPKD were selected from 1,000,000 general population after excluding patients with age<18, renal replacement therapy and concomitant diagnosis of CVA. Additionally, non-ADPKD subjects were assigned as comparison group by matching study cohort with age, gender, income and urbanization in 1:10 ratio (n=26,470). The results showed that ADPKD group had significantly higher frequency rate and cumulative incidence of CVA as compared with the non-ADPKD group (8.73% v.s. 3.93%, p<0.0001). Furthermore, the frequencies of both hemorrhagic and ischemic strokes were also significantly higher in the ADPKD than non-ADPKD group (all p-values <0.0001). After adjusting for age, gender and atherosclerotic risk factors with multivariate analysis, ADPKD independently carried 2.34- and 5.12-fold risk for occurrence of CVA and hemorrhagic stroke (95% CI: 2.02-2.72 and 4.01-6.54), respectively. Combination therapy [adjusted (a) HR=0.19, 95% CI: 0.11-0.31] was superior to either RAAS blockade (aHR=0.37, 95% CI, 0.28-0.5) or statin (aHR=0.44, 95% CI, 0.24-0.79) alone for reducing the CVA occurrence in the ADPKD population. In conclusion, ADPKD was associated with an increased risk of CVA occurrence. Combined RAAS blockade and statin therapy effectively reduces the risk of CVA in ADPKD.
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Affiliation(s)
- Pei-Hsun Sung
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Hsin-Ju Chiang
- Department of Obstetrics and Gynecology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan.,Chung Shan Medical University School of Medicine, Taichung, Taiwan
| | - Mel S Lee
- Department of Orthopedics, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - John Y Chiang
- Department of Computer Science and Engineering, National Sun Yat-Sen University, Kaohsiung, Taiwan.,Department of Healthcare Administration and Medical Informatics, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Hon-Kan Yip
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan.,Institute for Translational Research in Biomedicine and Center for Shockwave Medicine and Tissue Engineering, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan.,Department of Medical Research, China Medical University Hospital, China Medical University, Taichung, Taiwan.,Department of Nursing, Asia University, Taichung, Taiwan
| | - Yao-Hsu Yang
- Department for Traditional Chinese Medicine and Center of Excellence for Chang Gung Research Datalink, Chang Gung Memorial Hospital, Chiayi, Taiwan.,Institute of Occupational Medicine and Industrial Hygiene, National Taiwan University College of Public Health, Taipei, Taiwan.,School of Traditional Chinese Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan
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Lozano-Maneiro L, Puente-García A. Renin-Angiotensin-Aldosterone System Blockade in Diabetic Nephropathy. Present Evidences. J Clin Med 2015; 4:1908-37. [PMID: 26569322 PMCID: PMC4663476 DOI: 10.3390/jcm4111908] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Revised: 05/27/2015] [Accepted: 10/15/2015] [Indexed: 12/14/2022] Open
Abstract
Diabetic Kidney Disease (DKD) is the leading cause of chronic kidney disease in developed countries and its prevalence has increased dramatically in the past few decades. These patients are at an increased risk for premature death, cardiovascular disease, and other severe illnesses that result in frequent hospitalizations and increased health-care utilization. Although much progress has been made in slowing the progression of diabetic nephropathy, renal dysfunction and the development of end-stage renal disease remain major concerns in diabetes. Dysregulation of the renin-angiotensin-aldosterone system (RAAS) results in progressive renal damage. RAAS blockade is the cornerstone of treatment of DKD, with proven efficacy in many arenas. The theoretically-attractive option of combining these medications that target different points in the pathway, potentially offering a more complete RAAS blockade, has also been tested in clinical trials, but long-term outcomes were disappointing. This review examines the “state of play” for RAAS blockade in DKD, dual blockade of various combinations, and a perspective on its benefits and potential risks.
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Affiliation(s)
- Luz Lozano-Maneiro
- Division of Nephrology, Department of Internal Medicine, Fuenlabrada University Hospital, Rey Juan Carlos University School of Medicine, Camino del Molino, 2, 28942 Fuenlabrada, Madrid, Spain.
| | - Adriana Puente-García
- Division of Nephrology, Department of Internal Medicine, Fuenlabrada University Hospital, Rey Juan Carlos University School of Medicine, Camino del Molino, 2, 28942 Fuenlabrada, Madrid, Spain.
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