Key result
ACEI/ARBs are linked to ~36% lower mortality and reduced graft loss in kidney transplant recipients.
Why the study?
It remains controversial whether renin-angiotensin system inhibitors are beneficial to kidney transplant recipients for patient and allograft survival.
Does ACEI/ARB treatment reduce patient death and graft loss in kidney transplant recipients?
Meta-Analysis (n=54,096)
Does ACEI/ARB treatment reduce patient death and graft loss in kidney transplant recipients?
Relative Risk: 0.64 (95% CI 0.49–0.84)
ACEI/ARB treatment may reduce patient death and graft loss in kidney transplant recipients, though current evidence is largely driven by observational cohort studies rather than RCTs.
ACEI/ARB may lower death and graft loss risk after kidney transplant; leaves open need for confirmatory RCTs before practice change.
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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Jiang et al. (2017) conducted a meta-analysis in kidney transplant (n=54,096). ACEI/ARB vs. control was evaluated on patient death (RR 0.64, 95% CI 0.49-0.84). ACEI/ARB treatment was associated with decreased risks of patient death (RR 0.64; 95% CI 0.49-0.84) and graft loss (RR 0.59; 95% CI 0.47-0.74) in kidney transplant recipients.
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