ACE inhibitors and ARBs, alone or in combination, are the most effective strategies for prevention of end-stage kidney disease in adults with type 2 diabetes and kidney disease, a large meta-analysis in the Lancet finds.

The analysis of 157 studies and more than 43,000 adults did not support the use of β blockers, calcium-channel blockers, renin inhibitors, or diuretic monotherapy in this setting, said the researchers including Professor Jonathan Craig, a renal physician and professor of clinical epidemiology at the University of Sydney.

No blood pressure lowering regimen improved life expectancy, however compared with placebo, end-stage renal disease was significantly less likely after dual treatment with an ARB and an ACE inhibitor (odds ratio 0·62, 95% CI 0·43–0·90) and after ARB monotherapy (0·77, 0·65–0·92). 

The risks of drug-induced acute kidney injury and hyperkalaemia were similar for all drugs, although point estimates suggested clinically important effects on potassium and kidney function with dual ACE inhibitor and ARB treatment.

“In absolute terms, our findings suggest that giving 1000 adults with diabetes and kidney disease a combination of an ACE inhibitor and an ARB for 1 year might prevent 14 patients developing end-stage kidney disease and induce regression of albuminuria in 208, at the cost of 55 patients having acute kidney injury and 135 developing hyperkalemia,” the researchers wrote.

“Although our analysis suggests a somewhat greater efficacy of combination regimens for kidney function outcomes, treatment decisions are ultimately made after consideration of efficacy and safety,” they research team concluded.

Surveillance for treatment-related acute kidney injury and hyperkalaemia is important, as is better standardisation of the definitions of these adverse events and improved understanding of their outcomes, particularly in the context of future trials, they added.