Renin-Angiotensin-Aldosterone System Inhibition in Pediatric Chronic Kidney Disease

“The size of the PRESERVE study enabled us to compare the real-world effectiveness of the most widely used antihypertensive medications in children with CKD, and while observational, the results support using RAAS inhibitors as a first-line choice for treating high blood pressure in pediatric CKD.”

“The primary estimand of interest in this study was the effect of initiating calcium channel blockers (CCB) vs initiating renin-angiotensin-aldosterone system inhibition (RAASi), regardless of treatment changes, which is analogous to an intention-to-treat (ITT) estimand in a randomized clinical trial.... However, because the goal of this project was to guide clinicians in making treatment decisions about first-line therapy, the ITT estimand was most relevant. Subsequent treatment modifications, discontinuation, and switching are considered part of the real-world consequences of the initial treatment.”

“This is a timely and clinically relevant comparative effectiveness study evaluating two of the most commonly prescribed antihypertensive classes in pediatric CKD: angiotensin-converting enzyme (ACE) inhibitors and CCBs. This work should be of particular interest to the pediatric nephrology community, as it addresses a persistent gap between evidence generated under controlled trial conditions and the realities of day-to-day clinical practice. Rather than focusing on efficacy under idealized conditions, the authors directly compare two active, clinically relevant treatment options — precisely the decision clinicians face when selecting initial antihypertensive therapy for children with CKD.”