National and international guidelines endorse the use of two classes of drugs--angiotensin-converting-enzyme (ACE) inhibitors and angiotensin-II receptor blockers (ARB)--as the first-line blood pressure-lowering therapy in patients with kidney disease. Doctors have assumed that these drugs have specific effects to protect the kidney beyond those resulting from their ability to lower blood pressure.
Raymond MacAllister and colleagues (Centre for Clinical Pharmacology, University College, London) investigated to what extent this consensus is supported by the available evidence. They undertook a review and meta-analysis of 127 randomised controlled trials investigating the effect of different classes of blood pressure-lowering drugs on the progression of kidney disease. The researchers found that ACE inhibitors and ARBs were no better than other blood pressure-lowering drugs in preventing diabetic kidney disease, and it was unclear if they were more effective in non-diabetic kidney disease.
The authors state "There seems to be little justification for ACE inhibitors or ARBs to be first-line choices for renoprotection in diabetes on the basis of efficacy, and residual uncertainty still exists about the inherent value of these drugs in other renal disorders. In view of the present analysis, treatment decisions for hypertension in renal disease should be based on the blood-pressure-lowering effect, comparative tolerability, and cost of antihypertensive treatment."