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Cho M, Choi CY, Choi YJ, Rhie SJ. Clinical outcomes of renin angiotensin system inhibitor-based dual antihypertensive regimens in chronic kidney disease: a network meta-analysis. Sci Rep 2023; 13:5727. [PMID: 37029191 PMCID: PMC10082011 DOI: 10.1038/s41598-023-32266-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 03/24/2023] [Indexed: 04/09/2023] Open
Abstract
This study comprehensively investigated clinical outcomes associated with renin angiotensin system inhibitor-based dual antihypertensive regimens in non-dialysis chronic kidney disease (CKD) patients. Keyword searches of databases were performed per PRISMA-NMA guidelines. Frequentist network meta-analysis were conducted with 16 head-to-head randomized controlled trials. The effect sizes of dichotomous and continuous variables were estimated with odds ratio (OR) and standard mean differences (SMD), respectively. The protocol is registered in PROSPERO (CRD42022365927). Dual antihypertensive regimens with combination of angiotensin receptor blockers (ARB) and calcium channel blockers (CCB) demonstrated substantially reduced odd of major cardiovascular disease (CVD) events over other regimens including angiotensin converting enzyme inhibitor (ACEI) monotherapy (OR 3.19) and ARB monotherapy (OR 2.64). Most significant reductions in systolic (SBP) and diastolic blood pressure (DBP) were observed with ARB-based CCB dual regimen over ACEI monotherapy (SMD 17.60 SBP and 9.40 for DBP), ACEI-based CCB regimen (SMD 12.90 for SBP and 9.90 for DBP), and ARB monotherapy (SMD 13.20 for SBP and 5.00 for DBP). However, insignificant differences were noticed for the odds of hyperkalemia, end stage renal disease progression, and all-cause mortality. ARB-based CCB regimen has the greatest benefits on BP reduction as well as major CVD risks in non-dialysis CKD patients.
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Affiliation(s)
- Miseung Cho
- Graduate School of Converging Clinical & Public Health, Ewha Womans University, Seoul, 03760, Korea
| | - Chang-Young Choi
- Department of Internal Medicine, Ajou University Medical Center, Suwon, 16499, Korea
| | - Yeo Jin Choi
- Department of Pharmacy, College of Pharmacy, Kyung Hee University, 26 Kyungheedae-Ro, Dongdamun-Gu, Seoul, 02447, Korea.
- Department of Regulatory Science, Graduate School, Kyung Hee University, Seoul, 02447, Korea.
- Institute of Regulatory Innovation through Science (IRIS), Kyung Hee University, Seoul, 02447, Korea.
| | - Sandy Jeong Rhie
- Graduate School of Converging Clinical & Public Health, Ewha Womans University, Seoul, 03760, Korea.
- College of Pharmacy, Graduate School of Pharmaceutical Sciences, Ewha Womans University, 52 Ewhayeodae-Gil, Seodamun-Gu, Seoul, 03760, Korea.
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Randomized Controlled Trials on Renin Angiotensin Aldosterone System Inhibitors in Chronic Kidney Disease Stages 3–5: Are They Robust? A Fragility Index Analysis. J Clin Med 2022; 11:jcm11206184. [PMID: 36294504 PMCID: PMC9605379 DOI: 10.3390/jcm11206184] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 10/12/2022] [Accepted: 10/13/2022] [Indexed: 11/17/2022] Open
Abstract
Inhibition of the renin-angiotensin-aldosterone system (RAAS) is broadly recommended in many nephrological guidelines to prevent chronic kidney disease (CKD) progression. This work aimed to analyze the robustness of randomized controlled trials (RCTs) investigating the renal and cardiovascular outcomes in CKD stages 3–5 patients treated with RAAS inhibitors (RAASi). We searched for RCTs in MEDLINE (PubMed), EMBASE databases, and the Cochrane register. Fragility indexes (FIs) for every primary and secondary outcome were calculated according to Walsh et al., who first described this novel metric, suggesting 8 as the cut-off to consider a study robust. Spearman coefficient was calculated to correlate FI to p value and sample size of statistically significant primary and secondary outcomes. Twenty-two studies met the inclusion criteria, including 80,455 patients. Sample size considerably varied among the studies (median: 1693.5, range: 73–17,276). The median follow-up was 38 months (range 24–58). The overall median of both primary and secondary outcomes was 0 (range 0–117 and range 0–55, respectively). The median of FI for primary and secondary outcomes with a p value lower than 0.05 was 6 (range: 1–117) and 7.5 (range: 1–55), respectively. The medians of the FI for primary outcomes with a p value lower than 0.05 in CKD and no CKD patients were 5.5 (range 1–117) and 22 (range 1–80), respectively. Only a few RCTs have been shown to be robust. Our analysis underlined the need for further research with appropriate sample sizes and study design to explore the real potentialities of RAASi in the progression of CKD.
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Cheung AK, Chang TI, Cushman WC, Furth SL, Hou FF, Ix JH, Knoll GA, Muntner P, Pecoits-Filho R, Sarnak MJ, Tobe SW, Tomson CR, Mann JF. KDIGO 2021 Clinical Practice Guideline for the Management of Blood Pressure in Chronic Kidney Disease. Kidney Int 2021; 99:S1-S87. [PMID: 33637192 DOI: 10.1016/j.kint.2020.11.003] [Citation(s) in RCA: 391] [Impact Index Per Article: 130.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 11/02/2020] [Indexed: 12/19/2022]
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Owsiany MT, Hawley CE, Paik JM. Differential Diagnoses and Clinical Implications of Medication Nonadherence in Older Patients with Chronic Kidney Disease: A Review. Drugs Aging 2020; 37:875-884. [PMID: 33030671 DOI: 10.1007/s40266-020-00804-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/22/2020] [Indexed: 12/16/2022]
Abstract
Older adults with chronic kidney disease (CKD) often have many comorbidities, which requires them to take multiple medications. As the number of daily medications prescribed increases, the risk for polypharmacy increases. Understanding and improving medication adherence in this patient population is vital to avoiding the drug-related adverse events of polypharmacy. The primary objective of this review is to summarize the existing literature and to understand the factors leading to medication nonadherence in older patients with CKD. In this review, we discuss the prevalence of polypharmacy, the current lack of consensus on the incidence of medication nonadherence, the heterogeneity of assessing medication adherence, and the most common differential diagnoses for medication nonadherence in this population. Specifically, the most common differential diagnoses for medication nonadherence in older adults with CKD are (1) medication complexity; (2) cognitive impairment; (3) low health literacy; and (4) systems-based barriers. We provide tailored strategies to address these differential diagnoses and subsequently improve medication adherence. The clinical implications include deprescribing to decrease medication complexity and polypharmacy, utilizing a team-based approach to identify and support patients with cognitive impairment, enriching communication between health providers and patients with low health literacy, and improving health care access to address systems-based barriers. Further research is needed to determine the effects of addressing these differential diagnoses and medication adherence in older adults with CKD.
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Affiliation(s)
- Montgomery T Owsiany
- New England Geriatric Research, Education and Clinical Center, VA Boston Healthcare System, 150 South Huntington Avenue, Boston, MA, 12D-94, USA
| | - Chelsea E Hawley
- New England Geriatric Research, Education and Clinical Center, VA Boston Healthcare System, 150 South Huntington Avenue, Boston, MA, 12D-94, USA
| | - Julie M Paik
- New England Geriatric Research, Education and Clinical Center, VA Boston Healthcare System, 150 South Huntington Avenue, Boston, MA, 12D-94, USA. .,Renal Section, VA Boston Healthcare System, Boston, MA, USA. .,Renal Division and Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA. .,Harvard Medical School, Boston, MA, USA.
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Nagai K, Yamagata K, Iseki K, Moriyama T, Tsuruya K, Fujimoto S, Narita I, Konta T, Kondo M, Kasahara M, Shibagaki Y, Asahi K, Watanabe T. Antihypertensive treatment and risk of cardiovascular mortality in patients with chronic kidney disease diagnosed based on the presence of proteinuria and renal function: A large longitudinal study in Japan. PLoS One 2019; 14:e0225812. [PMID: 31800605 PMCID: PMC6892527 DOI: 10.1371/journal.pone.0225812] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 11/13/2019] [Indexed: 11/18/2022] Open
Abstract
Several recent clinical trials and meta-analyses have shown that lowering blood pressure reduces the risk of cardiovascular disease. However, current evidence that describes general demographics in blood pressure and mortality with chronic kidney disease is sparse in Japan. Using a population-based longitudinal cohort that received annual health checkups in Japan in 2008, hypertensive status, self-reported use of antihypertensive drugs, and prognosis were examined through 2012. Chronic kidney disease was defined as positive proteinuria or estimated glomerular filtration rate <60 ml/min/1.73 m2. Subjects were 40 to 74 years old (n = 227,204) with median 3.6 years follow-up period, and patients with and without chronic kidney disease were analyzed separately (n = 183,586 and n = 43,618, respectively). Cardiovascular disease mortality, comprising coronary heart diseases and stroke as entered in the national death registry using ICD-10 coding, was examined. Among all subjects, 346 deaths (96 in chronic kidney disease and 250 in non-chronic kidney disease) due to cardiovascular disease occurred. Compared with cardiovascular disease mortality in chronic kidney disease patients with untreated normal blood pressure, the multivariable adjusted hazard ratio was 3.08 (95% confidence interval: 1.75–5.41) for those with untreated hypertension, 2.30 (1.31–4.03) for those who became normotensive after treatment, and 3.28 (1.91–5.64) for those who remained hypertensive despite treatment. In non-chronic kidney disease subjects, the ratios were 1.90 (1.33–5.41), 1.95 (1.35–2.80), and 1.77 (1.18–2.66), respectively. These results from a nationwide cohort could be one of representative demographics of controlling blood pressure and cardiovascular disease deaths when treating patients with chronic kidney disease in Japan in recent years. Even after development and spread of anti-hypertensive drugs, preventing development of hypertension is preferable, because any hypertension treatment status comparing untreated normal blood pressure was a risk of cardiovascular mortality at baseline year.
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Affiliation(s)
- Kei Nagai
- University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Kunihiro Yamagata
- University of Tsukuba, Tsukuba, Ibaraki, Japan
- The Steering Committee for “Design of the Comprehensive Health Care System for Chronic Kidney Disease (CKD) Based on the Individual Risk Assessment by Specific Health Checkups”, Tsukuba, Ibaraki, Japan
- * E-mail:
| | - Kunitoshi Iseki
- The Steering Committee for “Design of the Comprehensive Health Care System for Chronic Kidney Disease (CKD) Based on the Individual Risk Assessment by Specific Health Checkups”, Tsukuba, Ibaraki, Japan
- Okinawa Heart and Renal Association, Okinawa, Japan
| | - Toshiki Moriyama
- The Steering Committee for “Design of the Comprehensive Health Care System for Chronic Kidney Disease (CKD) Based on the Individual Risk Assessment by Specific Health Checkups”, Tsukuba, Ibaraki, Japan
- Health Care Center, Osaka University, Suita, Japan
| | - Kazuhiko Tsuruya
- The Steering Committee for “Design of the Comprehensive Health Care System for Chronic Kidney Disease (CKD) Based on the Individual Risk Assessment by Specific Health Checkups”, Tsukuba, Ibaraki, Japan
- Nara Medical University, Nara, Japan
| | - Shouichi Fujimoto
- The Steering Committee for “Design of the Comprehensive Health Care System for Chronic Kidney Disease (CKD) Based on the Individual Risk Assessment by Specific Health Checkups”, Tsukuba, Ibaraki, Japan
- University of Miyazaki, Miyazaki, Japan
| | - Ichiei Narita
- The Steering Committee for “Design of the Comprehensive Health Care System for Chronic Kidney Disease (CKD) Based on the Individual Risk Assessment by Specific Health Checkups”, Tsukuba, Ibaraki, Japan
- Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Tsuneo Konta
- The Steering Committee for “Design of the Comprehensive Health Care System for Chronic Kidney Disease (CKD) Based on the Individual Risk Assessment by Specific Health Checkups”, Tsukuba, Ibaraki, Japan
- Yamagata University Graduate School of Medical Science, Yamagata, Japan
| | - Masahide Kondo
- University of Tsukuba, Tsukuba, Ibaraki, Japan
- The Steering Committee for “Design of the Comprehensive Health Care System for Chronic Kidney Disease (CKD) Based on the Individual Risk Assessment by Specific Health Checkups”, Tsukuba, Ibaraki, Japan
| | - Masato Kasahara
- The Steering Committee for “Design of the Comprehensive Health Care System for Chronic Kidney Disease (CKD) Based on the Individual Risk Assessment by Specific Health Checkups”, Tsukuba, Ibaraki, Japan
- Institute for Clinical and Translational Science, Nara Medical University Hospital, Nara, Japan
| | - Yugo Shibagaki
- The Steering Committee for “Design of the Comprehensive Health Care System for Chronic Kidney Disease (CKD) Based on the Individual Risk Assessment by Specific Health Checkups”, Tsukuba, Ibaraki, Japan
- St. Marianna University School of Medicine, Kawasaki, Kanagawa, Japan
| | - Koichi Asahi
- The Steering Committee for “Design of the Comprehensive Health Care System for Chronic Kidney Disease (CKD) Based on the Individual Risk Assessment by Specific Health Checkups”, Tsukuba, Ibaraki, Japan
- Iwate Medical University, Morioka, Japan
| | - Tsuyoshi Watanabe
- The Steering Committee for “Design of the Comprehensive Health Care System for Chronic Kidney Disease (CKD) Based on the Individual Risk Assessment by Specific Health Checkups”, Tsukuba, Ibaraki, Japan
- Fukushima Rosai Hospital, Iwaki, Japan
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Mishima E, Haruna Y, Arima H. Renin-angiotensin system inhibitors in hypertensive adults with non-diabetic CKD with or without proteinuria: a systematic review and meta-analysis of randomized trials. Hypertens Res 2019; 42:469-482. [DOI: 10.1038/s41440-018-0116-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Revised: 08/09/2018] [Accepted: 08/13/2018] [Indexed: 12/29/2022]
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Gregg LP, Hedayati SS. Management of Traditional Cardiovascular Risk Factors in CKD: What Are the Data? Am J Kidney Dis 2018; 72:728-744. [PMID: 29478869 PMCID: PMC6107444 DOI: 10.1053/j.ajkd.2017.12.007] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Accepted: 12/06/2017] [Indexed: 12/22/2022]
Abstract
Patients with non-dialysis-dependent chronic kidney disease (NDD-CKD) are 10 times more likely to die of cardiovascular (CV) diseases than the general population, and dialysis-dependent patients are at even higher risk. Although traditional CV risk factors are highly prevalent in individuals with CKD, these patients were often excluded from studies targeting modification of these risks. Although treatment of hypertension is beneficial in CKD, the best target blood pressure has not been established. Trial data showed that renin-angiotensin-aldosterone blockade may prevent CV events in patients with CKD. The risks of aspirin may equal the benefits in NDD-CKD samples, and there are no trials testing aspirin in dialysis-dependent patients. Lipid-lowering therapy improves CV outcomes in NDD-CKD, but not in dialysis-dependent patients. Strict glycemic control prevents CV events in nonalbuminuric individuals, but showed no benefit in those with baseline albuminuria with albumin excretion > 300mg/g, and there are no data in dialysis-dependent patients. Data for lifestyle modifications, such as weight loss, physical activity, and smoking cessation, are mostly observational and extrapolated from non-CKD samples. This comprehensive review summarizes the best existing evidence and current clinical guidelines for modification of traditional risk factors for the prevention of CV events in patients with CKD and identifies knowledge gaps.
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Affiliation(s)
- L Parker Gregg
- Division of Nephrology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, TX; Division of Nephrology, Medical Service, Veterans Affairs North Texas Health Care System, Dallas, TX.
| | - S Susan Hedayati
- Division of Nephrology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, TX
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Umemoto S, Ogihara T, Matsuzaki M, Rakugi H, Shimada K, Kawana M, Kario K, Ohashi Y, Saruta T. Effects of Calcium-Channel Blocker Benidipine-Based Combination Therapy on Cardiac Events - Subanalysis of the COPE Trial. Circ J 2017; 82:457-463. [PMID: 28867690 DOI: 10.1253/circj.cj-17-0592] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND The Combination Therapy of Hypertension to Prevent Cardiovascular Events (COPE) trial was conducted to compare the effects of regimens combining the dihydropyridine calcium-channel blocker benidipine with each of 3 secondary agent types (an angiotensin-receptor blocker (ARB), a β-blocker and a thiazide) in Japanese hypertensive outpatients who did not achieve target blood pressure (<140/90 mmHg) with benidipine 4 mg/day alone. The analysis included 3,293 patients (ARB, 1,110; β-blocker, 1,089; thiazide, 1,094) with a median follow-up of 3.61 years. The main results of the COPE trial demonstrated that the incidences of hard cardiovascular composite endpoints and fatal or non-fatal strokes were significantly higher in the benidipine/β-blocker group than in the benidipine/thiazide group.Methods and Results:We further evaluated the treatment effects on different cardiac events among the 3 benidipine-based regimens.We observed a total of 50 cardiac events, 4.2 per 1000 person-years. The incidences of total cardiac events and each cardiac event were similarly low among the 3 treatment groups. Unadjusted and multi-adjusted hazard ratios for total cardiac events showed no significant difference among the 3 treatment groups. CONCLUSIONS This subanalysis of the COPE trial demonstrated that blood pressure-lowering regimens combining benidipine with an ARB, β-blocker or thiazide diuretic were similarly effective for the prevention of cardiac events in Japanese hypertensive outpatients.
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Affiliation(s)
- Seiji Umemoto
- Center for Integrated Medical Research, Hiroshima University Hospital
| | - Toshio Ogihara
- Morinomiya University of Medical Sciences.,Department of Geriatric and General Medicine, Osaka University Graduate School of Medicine
| | | | - Hiromi Rakugi
- Department of Geriatric and General Medicine, Osaka University Graduate School of Medicine
| | | | - Masatoshi Kawana
- Department of General Medicine, Tokyo Women's Medical University Hospital
| | - Kazuomi Kario
- Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine
| | - Yasuo Ohashi
- Department of Integrated Science and Engineering for Sustainable Society, Faculty of Science and Engineering, Chuo University
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Hagiwara H, Nishikawa R, Fukuzawa K, Tohkin M. The Survey of the Compliance Situation to the Antihypertensive Therapy Guideline by Analyzing Japanese National Claims Data. YAKUGAKU ZASSHI 2017; 137:893-901. [DOI: 10.1248/yakushi.17-00038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Hiromi Hagiwara
- Department of Regulatory Science, Graduate School of Pharmaceutical Sciences, Nagoya City University
| | - Ryouhei Nishikawa
- Department of Regulatory Science, Graduate School of Pharmaceutical Sciences, Nagoya City University
| | - Kazuki Fukuzawa
- Department of Regulatory Science, Graduate School of Pharmaceutical Sciences, Nagoya City University
| | - Masahiro Tohkin
- Department of Regulatory Science, Graduate School of Pharmaceutical Sciences, Nagoya City University
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10
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Umemoto S, Ogihara T, Matsuzaki M, Rakugi H, Ohashi Y, Saruta T. Effects of calcium channel blocker benidipine-based combination therapy on target blood pressure control and cardiovascular outcome: a sub-analysis of the COPE trial. Hypertens Res 2017; 40:376-384. [PMID: 27904156 PMCID: PMC5506236 DOI: 10.1038/hr.2016.158] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2016] [Revised: 10/02/2016] [Accepted: 10/05/2016] [Indexed: 11/11/2022]
Abstract
We compared three benidipine-based regimens-that is, benidipine plus angiotensin receptor blocker (ARB), β-blocker (BB) or thiazide-and found that the benidipine-BB combination was less beneficial in reducing the risk of stroke than the benidipine-thiazide combination. This sub-analysis sought to compare the effects of reaching a target blood pressure (BP) (<140/90 mm Hg) on the cardiovascular outcomes among the three benidipine-based treatment groups in the Combination Therapy of Hypertension to Prevent Cardiovascular Events trial. This sub-analysis included 3001 subjects to evaluate the achievement of target BP at a minimum of three points at 6-month intervals of clinical BP measurements during the study period. After randomization, the patients were categorized into two groups on the basis of achieved on-treatment target BP: a good control (GC) group achieving a BP⩾66.7% of the target and a poor control (PC) group with a BP <66.6% of the target. For each of the two control groups, outcomes were compared among the three treatment groups. The event rates for cardiovascular composite endpoints, stroke and hard cardiovascular events were higher in the PC group than the GC group (P=0.041, P=0.042 and P=0.038, respectively). Within the PC group, hazard ratios for the incidence of cardiovascular events were lower in the benidipine-thiazide group than in the benidipine-BB group (composite cardiovascular events: 2.04, P=0.033; stroke: 4.14, P=0.005; and hard cardiovascular events: 3.52, P=0.009). Within the GC group, the incidence of cardiovascular events was not different among the three treatment regimens. The benidipine-thiazide combination may provide better cardiovascular outcomes than the benidipine-BB combination even in patients with poor BP control.
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Affiliation(s)
- Seiji Umemoto
- Center for Integrated Medical Research, Hiroshima University Hospital, Hiroshima, Japan
| | - Toshio Ogihara
- Morinomiya University of Medical Sciences, Osaka, Japan
- Department of Geriatric and General Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | | | - Hiromi Rakugi
- Department of Geriatric and General Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yasuo Ohashi
- Department of Integrated Science and Engineering for Sustainable Society, Faculty of Science and Engineering, Chuo University, Tokyo, Japan
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Chi C, Tai C, Bai B, Yu S, Karamanou M, Wang J, Protogerou A, Blacher J, Safar ME, Zhang Y, Xu Y. Angiotensin System Blockade Combined With Calcium Channel Blockers Is Superior to Other Combinations in Cardiovascular Protection With Similar Blood Pressure Reduction: A Meta-Analysis in 20,451 Hypertensive Patients. J Clin Hypertens (Greenwich) 2016; 18:801-8. [PMID: 26778747 DOI: 10.1111/jch.12771] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2015] [Revised: 11/21/2015] [Accepted: 11/23/2015] [Indexed: 11/29/2022]
Affiliation(s)
- Chen Chi
- Department of Cardiology; Shanghai Tenth People's Hospital; Tongji University School of Medicine; Shanghai China
| | - Chenhui Tai
- Department of Cardiology; Shanghai Tenth People's Hospital; Tongji University School of Medicine; Shanghai China
| | - Bin Bai
- Department of Cardiology; Shanghai Tenth People's Hospital; Tongji University School of Medicine; Shanghai China
| | - Shikai Yu
- Department of Cardiology; Shanghai Tenth People's Hospital; Tongji University School of Medicine; Shanghai China
| | - Marianna Karamanou
- University Institute of History of Medicine and Public Health; Lausanne Switzerland
| | - Jiguang Wang
- Shanghai Institute of Hypertension; Ruijin Hospital; Shanghai Jiaotong University School of Medicine; Shanghai China
| | - Athanase Protogerou
- Department of Pathophysiology; Laiko Hospital; Medical School; National and Kapodistrian University of Athens; Athens Greece
| | - Jacques Blacher
- Diagnosis and Therapeutic Center; Hôtel-Dieu Hospital; AP-HP; Paris Descartes University; Paris France
| | - Michel E. Safar
- Diagnosis and Therapeutic Center; Hôtel-Dieu Hospital; AP-HP; Paris Descartes University; Paris France
| | - Yi Zhang
- Department of Cardiology; Shanghai Tenth People's Hospital; Tongji University School of Medicine; Shanghai China
| | - Yawei Xu
- Department of Cardiology; Shanghai Tenth People's Hospital; Tongji University School of Medicine; Shanghai China
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12
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Xie X, Liu Y, Perkovic V, Li X, Ninomiya T, Hou W, Zhao N, Liu L, Lv J, Zhang H, Wang H. Renin-Angiotensin System Inhibitors and Kidney and Cardiovascular Outcomes in Patients With CKD: A Bayesian Network Meta-analysis of Randomized Clinical Trials. Am J Kidney Dis 2015; 67:728-41. [PMID: 26597926 DOI: 10.1053/j.ajkd.2015.10.011] [Citation(s) in RCA: 244] [Impact Index Per Article: 27.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2014] [Accepted: 10/10/2015] [Indexed: 02/06/2023]
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). STUDY DESIGN Systematic review and Bayesian network meta-analysis. SETTING & POPULATION Patients with CKD treated with renin-angiotensin system (RAS) inhibitors. SELECTION CRITERIA FOR STUDIES Randomized trials in patients with CKD treated with RAS inhibitors. PREDICTOR ACE inhibitors and ARBs compared to each other and to placebo and active controls. OUTCOME 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. LIMITATIONS 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.
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Affiliation(s)
- Xinfang Xie
- 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
| | - Youxia Liu
- 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
| | - Vlado Perkovic
- The George Institute for Global Health, the University of Sydney, Sydney, Australia
| | - Xiangling Li
- Department of Nephrology, Affiliated Hospital of Weifang Medical College, Weifang, Shandong, China
| | - Toshiharu Ninomiya
- The George Institute for Global Health, the University of Sydney, Sydney, Australia
| | - Wanyin Hou
- 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
| | - Na Zhao
- 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
| | - Lijun Liu
- 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
| | - Jicheng Lv
- 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.
| | - Hong Zhang
- 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.
| | - Haiyan Wang
- 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
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Umemoto S, Ogihara T, Matsuzaki M, Rakugi H, Ohashi Y, Saruta T. Effects of calcium channel blocker-based combinations on intra-individual blood pressure variability: post hoc analysis of the COPE trial. Hypertens Res 2015; 39:46-53. [PMID: 26490089 PMCID: PMC4709460 DOI: 10.1038/hr.2015.104] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2015] [Revised: 06/23/2015] [Accepted: 07/08/2015] [Indexed: 11/12/2022]
Abstract
Visit-to-visit blood pressure (BP) variability is an important predictor of stroke. However, which antihypertensive drug combination is better at reducing visit-to-visit BP variability and therefore at reducing stroke incidence remains uncertain. We have previously reported that the dihydropyridine calcium channel blocker benidipine combined with a β-blocker appeared to be less beneficial in reducing the risk of stroke than a combination of benidipine and thiazide. Here, we further compare the visit-to-visit BP variability among three benidipine-based regimens, namely angiotensin receptor blocker (ARB), β-blocker and thiazide combinations. The present post hoc analysis included 2983 patients without cardiovascular events or death during the first 18 months after randomization. We compared the BP variability (defined as the s.d. and the coefficient of variation (CV)), maximum systolic BP (SBP) and diastolic BP (DBP) of the clinic mean on-treatment BPs obtained at 6-month intervals, starting 6 months after the treatment initiation, among the 3 treatments (ARB, n=1026; β-blocker, n=966; thiazide, n=991). During the first 6–36 months after randomization, both the s.d. and CV-BPs were lower in the benidipine–thiazide group than in the benidipine–β-blocker group (s.d.-SBP, P=0.019; s.d.-DBP, P=0.030; CV-SBP, P=0.012; CV-DBP, P=0.022). The s.d. and CV in the ARB group did not reach statistical significance compared with the other two groups. The maximum BPs did not differ among the three treatments. These findings suggest that the benidipine–thiazide combination may reduce visit-to-visit BP variability more than the benidipine–β-blocker combination.
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Affiliation(s)
- Seiji Umemoto
- Center for Clinical Research, Yamaguchi University Hospital, Yamaguchi, Japan
| | - Toshio Ogihara
- Morinomiya University of Medical Sciences, Osaka, Japan.,Department of Geriatric Medicine and Nephrology, Osaka University Graduate School of Medicine, Osaka, Japan
| | | | - Hiromi Rakugi
- Department of Geriatric Medicine and Nephrology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yasuo Ohashi
- Department of Integrated Science and Engineering for Sustainable Society, Faculty of Science and Engineering, Chuo University, Tokyo, Japan
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Abe M, Soma M. Multifunctional L/N- and L/T-type calcium channel blockers for kidney protection. Hypertens Res 2015; 38:804-6. [PMID: 26423789 DOI: 10.1038/hr.2015.106] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
- Masanori Abe
- Division of Nephrology, Hypertension and Endocrinology, Department of Internal Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Masayoshi Soma
- Division of Nephrology, Hypertension and Endocrinology, Department of Internal Medicine, Nihon University School of Medicine, Tokyo, Japan.,Division of General Medicine, Department of Internal Medicine, Nihon University School of Medicine, Tokyo, Japan
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Thamcharoen N, Susantitaphong P, Wongrakpanich S, Chongsathidkiet P, Tantrachoti P, Pitukweerakul S, Avihingsanon Y, Praditpornsilpa K, Jaber BL, Eiam-Ong S. Effect of N- and T-type calcium channel blocker on proteinuria, blood pressure and kidney function in hypertensive patients: a meta-analysis. Hypertens Res 2015; 38:847-55. [PMID: 26134125 DOI: 10.1038/hr.2015.69] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2015] [Revised: 05/12/2015] [Accepted: 05/27/2015] [Indexed: 12/28/2022]
Abstract
The combination of a calcium channel blocker (CCB) and a blocker of the renin-angiotensin-aldosterone system (RAAS) is recommended in clinical practice guidelines. L/N- and L/T-type CCBs might provide an additional effect on lowering proteinuria. Therefore, we conducted a meta-analysis to assess the efficacy of L/N- and L/T-type CCBs in hypertensive patients with proteinuria. We searched MEDLINE, Scopus, Cochrane Central Register of Controlled Trials and ClinicalTrials.gov for single-arm studies and randomized controlled trials (RCTs) that examined the effect of L/N- and L/T-type CCBs as add-on therapy compared with standard antihypertensive regimen for proteinuria on hemodynamic and kidney-related parameters in hypertensive patients with proteinuria. Random-effect model meta-analyses were used to compute changes in the outcomes of interest. We identified 17 RCTs, representing 1905 patients. By meta-analysis, L/N- and L/T-type CCB add-on therapy did not yield significant changes in systolic and diastolic blood pressure compared with standard treatment, but there was a significant lowering of the pulse rate. However, L/N- and L/T-type CCBs resulted in a significant standardized net decrease in albuminuria and proteinuria (-1.01; 95% confidence interval (CI), -1.78 to -0.23; P=0.01), and a standardized net improvement in the estimated glomerular filtration rate and serum creatinine (0.23; 95% CI, 0.11 to 0.35, P<0.001; and -0.25; 95% CI, -0.46 to -0.03; P=0.02, respectively). Despite no additional lowering effect on blood pressure, L/N- and L/T-type CCBs combined with a blocker of the RAAS provided a decrease in proteinuria and improvement in kidney function. Further studies are required to establish the long-term kidney benefits of this combination therapy.
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Affiliation(s)
- Natanong Thamcharoen
- Division of Nephrology, Department of Medicine, King Chulalongkorn Memorial Hospital, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Paweena Susantitaphong
- Division of Nephrology, Department of Medicine, King Chulalongkorn Memorial Hospital, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Department of Medicine, Tufts University School of Medicine, Boston, MA, USA
| | - Supakanya Wongrakpanich
- Division of Nephrology, Department of Medicine, King Chulalongkorn Memorial Hospital, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Pakawat Chongsathidkiet
- Division of Nephrology, Department of Medicine, King Chulalongkorn Memorial Hospital, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Pakpoom Tantrachoti
- Division of Nephrology, Department of Medicine, King Chulalongkorn Memorial Hospital, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Siwadon Pitukweerakul
- Division of Nephrology, Department of Medicine, King Chulalongkorn Memorial Hospital, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Yingyos Avihingsanon
- Division of Nephrology, Department of Medicine, King Chulalongkorn Memorial Hospital, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Kearkiat Praditpornsilpa
- Division of Nephrology, Department of Medicine, King Chulalongkorn Memorial Hospital, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Bertrand L Jaber
- Department of Medicine, Tufts University School of Medicine, Boston, MA, USA.,Department of Medicine, St Elizabeth's Medical Center, Boston, MA, USA
| | - Somchai Eiam-Ong
- Division of Nephrology, Department of Medicine, King Chulalongkorn Memorial Hospital, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
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Differential effectiveness of ARB plus CCB therapy and high-dose ARB therapy in high-risk elderly hypertensive patients: subanalysis of the OSCAR study. Hypertens Res 2014; 38:199-207. [PMID: 25471234 DOI: 10.1038/hr.2014.164] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2014] [Revised: 09/26/2014] [Accepted: 10/23/2014] [Indexed: 01/01/2023]
Abstract
The OSCAR study was a multicenter prospective randomized study that examined the relative benefit of combined ARB (olmesartan 20 mg per day) plus calcium channel blocker (CCB) therapy vs. high-dose ARB monotherapy (olmesartan 40 mg per day) for prevention of cardiovascular events in elderly Japanese hypertensive patients. The present subanalysis of patients enrolled in the OSCAR study (n = 1078) was performed to assess whether baseline eGFR coupled with cardiovascular disease (CVD) could predict the relative benefit of these two treatments. Patients with baseline CVD (n = 769) and patients without baseline CVD (n = 309) were divided into two groups based on baseline eGFR; (i) patients with eGFR of < 60 ml min(-1) 1.73 m(-)(2) and (ii) those with eGFR of ⩾ 60 ml min(-1) 1.73 m(-2). There was a significant treatment-subgroup interaction among these four subgroups in relation to the incidence of primary outcome events(P = 0.007 for interaction). In patients with CVD and with eGFR of <60 ml min(-1) 1.73 m(-2), ARB plus CCB therapy was associated with a lower incidence of primary events than high-dose ARB therapy and the difference of the relative risk was statistically significant (hazard ratio: 3.525, 95% confidence interval (CI): 1.676-7.412, P < 0.001). The greater benefit of ARB plus CCB therapy vs. high-dose ARB therapy in this subgroup was associated with less visit-to-visit variability of systolic BP and diastolic BP. In conclusion, baseline eGFR coupled with baseline CVD seems to be a predictor of the relative efficacy of ARB plus CCB therapy vs. high-dose ARB therapy in the elderly hypertensive patients. ARB plus CCB therapy appears to be superior to high-dose ARB therapy for preventing cardiovascular events in the patients with CVD and with eGFR of <60 ml min(-1) 1.73 m(-2).
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Tamura K, Ohki K, Kobayashi R, Uneda K, Azushima K, Ohsawa M, Wakui H, Sakai M, Tokita Y, Umemura S. Therapeutic impact of the single fixed-dose combination with a high-dose angiotensin-receptor blocker and a low-dose thiazide diuretic in the management of hypertension: awaiting further accumulation of clinical evidence. Hypertens Res 2014; 37:1032-4. [DOI: 10.1038/hr.2014.130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Tani S, Takahashi A, Nagao K, Hirayama A. Effects of the T/L-type calcium channel blocker benidipine on albuminuria and plasma aldosterone concentration. A pilot study involving switching from L-type calcium channel blockers to benidipine. Int Heart J 2014; 55:519-25. [PMID: 25310932 DOI: 10.1536/ihj.14-034] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Albuminuria and a high plasma aldosterone concentration (PAC) are prognosis factors predicting a poor outcome for cardiovascular disease. We examined here the effects of benidipine, a T/L-type calcium channel blocker (CCB), on albuminuria and PAC.Thirty-one patients with essential hypertension who received an L-type CCB and achieved the target blood pressure (BP) indicated by the Treatment Guidelines of the Japan Society of Hypertension (JSH2009) were investigated. The Ltype CCB under treatment was switched to benidipine at a dose in which equivalent BP reduction was expected. BP and estimated glomerular filtration rate at 6 months after switching to benidipine were not significantly different from those at baseline. The urinary-albumin-creatinine ratio (UACR) decreased significantly by 36.9% (P = 0.001). No significant change was observed in plasma renin activity (P = 0.063). The PAC of all patients decreased significantly by 11.8% (P = 0.002). When analyzed by daily doses of benidipine, the PAC appeared to have decreased in patients who received 4 mg per day of benidipine (n = 14), although statistical significance was not reached (P = 0.096). The PAC in patients who received 8 mg per day of benidipine (n =17) was significantly reduced by 13.2% (P = 0.017).In hypertensive patients whose BP is controlled by L-type CCB, switching to the T/L-type CCB benidipine maintained BP control and reduced UACR. In addition, the high dose of benidipine reduced the PAC independent of BP control. These results suggest the T/L-type CCB benidipine may contribute to cardio-renal protection in addition to lowering BP.
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Affiliation(s)
- Shigemasa Tani
- Department of Cardiology, Surugadai Nihon University Hospital
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Do patients with chronic kidney disease get optimal cardiovascular risk reduction? Curr Opin Nephrol Hypertens 2014; 23:267-74. [DOI: 10.1097/01.mnh.0000444913.78536.b1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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