Options for BP Control in Diabetic Kidney Disease

No BP-lowering medication strategy leads to increased survival in diabetic patients with kidney disease, concludes a network meta-analysis in The Lancet.

A systematic literature search was performed to identify randomized trials comparing the outcomes of treatment with oral BP-lowering drugs in adults with diabetes and kidney disease. A random-effects network meta-analysis included 157 studies comprising more than 43,000 patients—most with type 2 diabetes and chronic kidney disease. All-cause mortality and ESRD were the main outcomes of interest; secondary safety and cardiovascular outcomes were evaluated as well.

The analysis identified no drug treatment that reduced all-cause mortality, compared with placebo. However, strategies using an angiotensin-receptor blocker (ARB) were associated with a significant reduction in ESRD compared with placebo. The odds ratios for this outcome were 0.77 with ARB monotherapy and 0.62 with ARB plus an angiotensin-converting enzyme inhibitor. The results for the primary outcomes were “generally robust” in sensitivity analyses.

No treatment strategy was associated with an increased risk of hyperkalemia or acute kidney injury. However, the combination of ARB and angiotensin-converting enzyme (ACE) inhibitor was associated with borderline increases, making it the lowest-ranked treatment for both safety outcomes.

There is continued debate over the relative safety and efficacy of different BP-lowering drugs, mainly because of the lack of head-to-head comparisons. Although ARBs and ACE inhibitors are assumed to be clinically equivalent, their concurrent use is not recommended.

Within its limitations, the network meta-analysis suggests that no BP-lowering treatment reduces mortality in diabetic patients with kidney disease. The use of ARBs and ACE inhibitors, alone or in combination, appears most effective against ESRD. The authors emphasize the need for close follow-up for treatment-related acute kidney injury and hyperkalemia in patients receiving these drugs [Palmer SC, et al. Comparative efficacy and safety of blood pressure-lowering agents in adults with diabetes and kidney disease: a network meta-analysis. Lancet 2015; 385:2047–2056].