ACE inhibitors may be associated with superior outcomes compared with angiotensin II receptor blockers (ARBs) in patients with chronic kidney disease (CKD), including lower risks of kidney failure and death, a new systematic review and meta-analysis finds.

Investigators led by Xinfang Xie, PhD, and Youxia Liu, PhD, of Peking University in Beijing, China, pooled results from 119 randomized, controlled trials of renin-angiotensin system (RAS) inhibitors involving 64,768 CKD patients. The RAS inhibitors were compared with other active controls, each other, and/or placebo. Trials comparing other blood pressure-lowering drugs were excluded.

Results showed that ACE inhibitors and ARBs were more effective at reducing the risk of kidney failure: 39% and 30%, respectively, compared with placebo and 35% and 25%, respectively, compared with active controls. Active control drugs did not appear to have a significant protective effect.

Continue Reading

Both ACE inhibitors and ARBs also reduced the odds of major cardiovascular events by 18% and 24%, respectively, compared with placebo. Researchers observed no significant effect for cardiovascular death, however.

Importantly, ACE inhibitors significantly reduced the chances of death from any cause compared with active controls. The medications were also consistently associated with decreased odds of kidney failure, cardiovascular death, or death from any cause compared with ARBs.

“ACE inhibitors and ARBs have been recommended in an interchangeable fashion in most guidelines for the treatment of people with kidney disease,” investigators explained in a paper published online ahead of print in the American Journal of Kidney Diseases. “The available data, summarized in this review, suggest that the benefits of ACE inhibitors in terms of kidney protection and mortality are greater than those of ARBs.” This difference could be due to different actions of ACE inhibitors and ARBs on the RAS pathway, they noted. For example, ACE inhibitors inhibit bradykinin degradation, which may improve endothelial function.

The researchers acknowledged a few study limitations, including a focus that excluded trials of other blood pressure-lowering drugs. The possibility of reporting bias also exists.


  1. Xie X, Liu Y, Perkovic V, et al. 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. doi: 10.1053/j.ajkd.2015.10.011.