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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: 389] [Impact Index Per Article: 129.7] [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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2
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Tsuchimoto A, Masutani K, Ueki K, Nakagawa K, Matsukuma Y, Tanaka S, Unagami K, Kakuta Y, Okumi M, Noguchi H, Kaku K, Okabe Y, Nakano T, Kitazono T, Nakamura M, Ishida H, Tanabe K. Effect of renin–angiotensin system blockade on graft survival and cardiovascular disease in kidney transplant recipients: retrospective multicenter study in Japan. Clin Exp Nephrol 2019; 24:369-378. [DOI: 10.1007/s10157-019-01827-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 11/25/2019] [Indexed: 01/13/2023]
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3
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Pisano A, Bolignano D, Mallamaci F, D’Arrigo G, Halimi JM, Persu A, Wuerzner G, Sarafidis P, Watschinger B, Burnier M, Zoccali C. Comparative effectiveness of different antihypertensive agents in kidney transplantation: a systematic review and meta-analysis. Nephrol Dial Transplant 2019; 35:878-887. [DOI: 10.1093/ndt/gfz092] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Accepted: 04/11/2019] [Indexed: 12/19/2022] Open
Abstract
Abstract
Background
We conducted a systematic review and meta-analysis to compare benefits and harms of different antihypertensive drug classes in kidney transplant recipients, as post-transplant hypertension (HTN) associates with increased cardiovascular (CV) morbidity and mortality.
Methods
The Ovid-MEDLINE, PubMed and CENTRAL databases were searched for randomized controlled trials (RCTs) comparing all main antihypertensive agents versus placebo/no treatment, routine treatment.
Results
The search identified 71 RCTs. Calcium channel blockers (CCBs) (26 trials) reduced the risk for graft loss {risk ratio [RR] 0.58 [95% confidence interval (CI) 0.38–0.89]}, increased glomerular filtration rate (GFR) [mean difference (MD) 3.08 mL/min (95% CI 0.38–5.78)] and reduced blood pressure (BP). Angiotensin-converting enzyme inhibitors (ACEIs) (13 trials) reduced the risk for graft loss [RR 0.62 (95% CI 0.40–0.96)] but decreased renal function and increased the risk for hyperkalaemia. Angiotensin receptor blockers (ARBs) (10 trials) did not modify the risk of death, graft loss and non-fatal CV events and increased the risk for hyperkalaemia. When pooling ACEI and ARB data, the risk for graft failure was lower in renin–angiotensin system (RAS) blockade as compared with control treatments. In direct comparison with ACEIs or ARBs (11 trials), CCBs increased GFR [MD 11.07 mL/min (95% CI 6.04–16.09)] and reduced potassium levels but were not more effective in reducing BP. There are few available data on mortality, graft loss and rejection. Very few studies performed comparisons with other active drugs.
Conclusions
CCBs could be the preferred first-step antihypertensive agents in kidney transplant patients, as they improve graft function and reduce graft loss. No definite patient or graft survival benefits were associated with RAS inhibitor use over conventional treatment.
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Affiliation(s)
- Anna Pisano
- CNR-Institute of Clinical Physiology, Clinical Epidemiology and Physiopathology of Renal Diseases and Hypertension, Reggio Calabria, Italy
| | - Davide Bolignano
- CNR-Institute of Clinical Physiology, Clinical Epidemiology and Physiopathology of Renal Diseases and Hypertension, Reggio Calabria, Italy
| | - Francesca Mallamaci
- CNR-Institute of Clinical Physiology, Clinical Epidemiology and Physiopathology of Renal Diseases and Hypertension, Reggio Calabria, Italy
| | - Graziella D’Arrigo
- CNR-Institute of Clinical Physiology, Clinical Epidemiology and Physiopathology of Renal Diseases and Hypertension, Reggio Calabria, Italy
| | - Jean-Michel Halimi
- Service de Néphrologie et Immunologie clinique, CHRU de Tours—Hôpital Bretonneau, Tours, France
| | - Alexandre Persu
- Division of Cardiology, Cliniques Universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium
- Pole of Cardiovascular Research, Institut de Recherche Expérimentale et Clinique, Université catholique de Louvain, Brussels, Belgium
| | - Gregoire Wuerzner
- Service of Nephrology and Hypertension, University Hospital, Lausanne, Switzerland
| | | | - Bruno Watschinger
- Department of Internal Medicine III, Division of Nephrology, Medical University of Vienna, Vienna, Austria
| | - Michel Burnier
- Service of Nephrology and Hypertension, University Hospital, Lausanne, Switzerland
| | - Carmine Zoccali
- CNR-Institute of Clinical Physiology, Clinical Epidemiology and Physiopathology of Renal Diseases and Hypertension, Reggio Calabria, Italy
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Jiang YM, Song TR, Qiu Y, Liu JP, Wang XD, Huang ZL, Lin T. Effect of renin-angiotensin system inhibitors on survival in kidney transplant recipients: A systematic review and meta-analysis. Kaohsiung J Med Sci 2018; 34:1-13. [PMID: 29310811 DOI: 10.1016/j.kjms.2017.07.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2017] [Revised: 05/10/2017] [Accepted: 07/27/2017] [Indexed: 11/25/2022] Open
Abstract
Renin-angiotensin system inhibitors, specifically angiotensin II converting enzyme inhibitors (ACEI) and angiotensin II receptor blockers (ARB), have confirmed renoprotective benefits in patients with proteinuria and hypertension. However, it remains controversial whether these agents are beneficial to kidney recipients. We conducted this meta-analysis to evaluate the effects of ACEI/ARB treatment on patient and allograft survival after kidney transplant. The PubMed, Embase and Cochrane Library databases were searched for eligible articles from before May 2016, and we included 24 articles (9 randomised controlled trials [RCTs] and 15 cohort studies with 54,096 patients), in which patient or graft survival was compared between an ACEI/ARB treatment arm and a control arm. Pooled results showed that ACEI/ARB was associated with decreased risks of patient death (relative risk [RR] = 0.64; 95% confidence interval [CI]:0.49-0.84) and graft loss (RR = 0.59; 95%CI:0.47-0.74). Subgroup analysis of the cohorts revealed significantly reduced patient death (RR = 0.61; 95%CI:0.50-0.74) and graft loss (RR = 0.58; 95%CI:0.46-0.73), but this was not seen in RCTs (patient survival: RR = 0.84, 95%CI:0.39-1.81; graft survival: RR = 0.70, 95%CI:0.17-2.79). Significantly less graft loss was noted among patients with biopsy-proved chronic allograft nephropathy (CAN) (RR = 0.26, 95%CI:0.16-0.44). Furthermore, the benefit of ACEI/ARB on patient survival (RR = 0.62; 95%CI:0.47-0.83) and graft survival (RR = 0.58, 95%CI:0.47-0.71) was limited to those with ≥3years' follow-up. ACEI/ARB decreased proteinuria (P < 0.001) and lowered haemoglobin (P = 0.002), but the haemoglobin change requires no additional treatment (from 119-131 g/L to 107-123 g/L). We therefore concluded that ACEI/ARB treatment may reduce patient death and graft loss, but additional well-designed prospective studies are needed to validate these findings.
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Affiliation(s)
- Ya-Mei Jiang
- Department of Urology, Urology Institute and Organ Transplantation Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Tu-Run Song
- Department of Urology, Urology Institute and Organ Transplantation Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yang Qiu
- Department of Urology, Urology Institute and Organ Transplantation Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Jin-Peng Liu
- Department of Urology, Urology Institute and Organ Transplantation Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Xian-Ding Wang
- Department of Urology, Urology Institute and Organ Transplantation Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Zhong-Li Huang
- Department of Urology, Urology Institute and Organ Transplantation Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Tao Lin
- Department of Urology, Urology Institute and Organ Transplantation Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China.
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Liao RX, Lyu XF, Tang WJ, Gao K. Short- and long-term outcomes with renin-angiotensin-aldosterone inhibitors in renal transplant recipients: A meta-analysis of randomized controlled trials. Clin Transplant 2017; 31. [PMID: 28186357 DOI: 10.1111/ctr.12917] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/21/2017] [Indexed: 02/05/2023]
Affiliation(s)
- Ruo-xi Liao
- Department of Nephrology; West China Hospital; Sichuan University; Chengdu China
| | - Xia-fei Lyu
- Department of Radiology; West China Hospital; Sichuan University; Chengdu China
| | - Wen-jiao Tang
- Department of Hematology; West China Hospital; Sichuan University; Chengdu China
| | - Kai Gao
- Department of Computer Science and Technology; Tsinghua University; Beijing China
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Hiremath S, Fergusson DA, Fergusson N, Bennett A, Knoll GA. Renin-Angiotensin System Blockade and Long-term Clinical Outcomes in Kidney Transplant Recipients: A Meta-analysis of Randomized Controlled Trials. Am J Kidney Dis 2017; 69:78-86. [DOI: 10.1053/j.ajkd.2016.08.018] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Accepted: 08/04/2016] [Indexed: 11/11/2022]
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7
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Mandelbrot DA, Alberú J, Barama A, Marder BA, Silva HT, Flechner SM, Flynn A, Healy C, Li H, Tortorici MA, Schulman SL. Effect of Ramipril on Urinary Protein Excretion in Maintenance Renal Transplant Patients Converted to Sirolimus. Am J Transplant 2015; 15:3174-84. [PMID: 26176342 DOI: 10.1111/ajt.13384] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2014] [Revised: 05/17/2015] [Accepted: 05/17/2015] [Indexed: 01/25/2023]
Abstract
This prospective, randomized, double-blind, placebo-controlled study evaluated the effects of ramipril on urinary protein excretion in renal transplant patients treated with sirolimus following conversion from a calcineurin inhibitor. Patients received ramipril or placebo for up to 6 weeks before conversion and 52 weeks thereafter. Doses were increased if patients developed proteinuria (urinary protein/creatinine ratio ≥0.5); losartan was given as rescue therapy for persistent proteinuria. The primary end point was time to losartan initiation. Of 295 patients randomized, 264 met the criteria for sirolimus conversion (ramipril, 138; placebo, 126). At 52 weeks, the cumulative rate of losartan initiation was significantly lower with ramipril (6.2%) versus placebo (23.2%) (p < 0.001). No significant differences were observed between ramipril and placebo for change in glomerular filtration rate from baseline (p = 0.148) or in the number of patients with biopsy-confirmed acute rejection (13 vs. 5, respectively; p = 0.073). One patient in the placebo group died due to cerebrovascular accident. Treatment-emergent adverse events were consistent with the known safety profile of sirolimus and were not potentiated by ramipril co-administration. Ramipril was effective in reducing the incidence of proteinuria for up to 1 year following conversion to sirolimus in maintenance renal transplant patients.
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Affiliation(s)
- D A Mandelbrot
- Department of Medicine, University of Wisconsin Hospital, Madison, WI
| | - J Alberú
- Transplantation Department, Instituto Nacional de Ciencias Médicas y Nutrición SZ, Mexico City, Mexico
| | - A Barama
- Department of Surgery, University of Montréal, Quebec, Canada
| | - B A Marder
- Internal Medicine/Nephrology, Presbyterian/St Luke's Medical Center, Denver, CO
| | - H T Silva
- Nephrology Division, Hospital do Rim-Universidade Federal de São Paulo, São Paulo, Brazil
| | - S M Flechner
- Glickman Urological and Kidney Institute, Cleveland Clinic Lerner College of Medicine, Cleveland, OH
| | - A Flynn
- Global Innovative Pharma, Pfizer, Collegeville, PA
| | - C Healy
- Global Innovative Pharma, Pfizer, Collegeville, PA
| | - H Li
- Global Innovative Pharma, Pfizer, Collegeville, PA
| | | | - S L Schulman
- Global Innovative Pharma, Pfizer, Collegeville, PA
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Ruiz JC, Sánchez-Fructuoso A, Zárraga S. Management of proteinuria in clinical practice after kidney transplantation. Transplant Rev (Orlando) 2012; 26:36-43. [DOI: 10.1016/j.trre.2011.07.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2011] [Accepted: 07/28/2011] [Indexed: 01/06/2023]
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10
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Shamseddin MK, Knoll GA. Posttransplantation proteinuria: an approach to diagnosis and management. Clin J Am Soc Nephrol 2011; 6:1786-93. [PMID: 21734095 DOI: 10.2215/cjn.01310211] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Proteinuria is a common problem encountered in the treatment of renal transplant recipients, occurring in up to 45% of patients. Proteinuria from native kidneys falls rapidly after renal transplantation, and persistent or worsening proteinuria is usually indicative of allograft pathology. Biopsy studies of transplant patients with proteinuria have confirmed that transplant-specific diagnoses (transplant glomerulopathy, interstitial fibrosis and tubular atrophy, and acute rejection) are more commonly found than other proteinuric conditions, such as glomerulonephritis. As in the nontransplant setting, proteinuria is associated with worse clinical outcomes, including an increased risk for death, cardiovascular events, and graft loss. Blockade of the renin-angiotensin-aldosterone system with angiotensin-converting enzyme inhibitors and angiotensin receptor blockers will reduce proteinuria, but the long-term effect of these medications on patient and graft survival remains unknown.
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Affiliation(s)
- M Khaled Shamseddin
- Division of Nephrology, Faculty of Medicine, University of Ottawa Hospital, Ottawa, Ontario, Canada
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Hernández AA, Moreso F, Bayés B, Lauzurica R, Sánz-Guajardo D, Gómez-Huertas E, Pereira P, Paul J, Crespo J, Amenábar JJ, Oliver J, Serón D. Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers in renal transplantation between 1990 and 2002 in Spain. Clin Kidney J 2010; 3:ii21-ii25. [PMID: 20508862 PMCID: PMC2875045 DOI: 10.1093/ndtplus/sfq068] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2009] [Accepted: 03/29/2010] [Indexed: 01/13/2023] Open
Abstract
Background. Angiotensin-converting enzyme inhibitors (ACEI) and angiotensin II type 1 receptor blockers (ARB) decrease cardiovascular mortality and slow the progression of renal disease in non-transplant patients, but their impact on kidney transplant outcome has not been well established. Methods. Patients receiving a renal allograft in Spain in 1990, 1994, 1998 and 2002 were considered for the present study. Only adult (≥18 years) recipients of a single kidney transplant functioning at the end of the first year were considered. A total of 4842 patients with clinical data about ACEI/ARB therapy were included. Results. During the initial 2 years after transplant, ACEI/ARB were less frequently used in the 1990 and 1994 cohorts than in 1998 and 2002 (15.1%, 24.6%, 33.5% and 45.1%, respectively; P < 0.001). During the first year, a total of 1063 patients (22.8%) received ACEI/ARB treatment, and graft survival (50.0% for treated patients and 51.4% for untreated, P = ns), death-censored graft survival (60.6% versus 63.5%, P = ns) and patient survival (68.8% versus 66.6%, P = ns) were not different. During the initial 2 years, 1472 patients (31.4%) received treatment with ACEI/ARB, and graft survival tended to be higher in treated patients (54.4% and 50.9%, P = 0.063). Since there was an interaction between ACEI/ARB treatment and year of transplant, graft survival was analysed in each cohort. Cox regression analysis including the propensity score for ACEI/ARB treatment showed an association between ACEI/ARB treatment and graft survival in the 2002 cohort (relative risk 0.36 and 95% confidence interval 0.17–0.75, P = 0.007). Death-censored graft survival (63.8% versus 63.1%, P = ns) and patient survival (68.1% and 66.5%, P = ns) were not significantly different. Conclusions. The use of ACEI/ARB during the initial 2 years after transplantation was associated with a better graft survival, but this effect was only observed in the 2002 cohort.
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