Comparative effectiveness of angiotensin-converting enzyme inhibitors versus angiotensin II receptor blockers for major renal outcomes in patients with diabetes: A 15-year cohort study

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Abstract

Background

Angiotensin converting enzyme inhibitors (ACEIs) and angiotensin II receptor blockers (ARBs) are considered to have similar renoprotective effects; so far there has been no consensus about their priorities. This study aimed to compare ACEIs and ARBs for major renal outcomes and survival in a 15-year cohort of adults with diabetes.

Methods

This study utilized Taiwan’s medical and pharmacy claims data in the Longitudinal Cohort of Diabetes Patients. The primary outcome was long-term dialysis, and secondary outcomes were hospitalization for acute kidney injury, hospitalization for hyperkalemia, all-cause death, cardiovascular death, and non-cardiovascular death. Cox proportional hazards models were used to estimate the hazard ratios (HRs) and 95% confidence intervals (CIs) for outcomes comparing ACEIs with ARBs. We conducted subgroup analyses and interaction tests among patients with different age and comorbid diseases.

Results

A total of 34,043 patients received ACEIs and 23,772 patients received ARBs. No differences were found for primary or secondary outcomes in the main analyses. ACEIs showed significantly lower hazard than ARBs for long-term dialysis among patients with cardiovascular disease (HR 0.80, 95% CI 0.66–0.97, interaction P = 0.003) or chronic kidney disease (0.81, 0.71–0.93, interaction P = 0.001).

Conclusions

Our analyses show similar effects of ACEIs and ARBs in patients with diabetes. However, ACEIs might provide additional renoprotective effects among patients who have cardiovascular disease or chronic kidney disease.

Related collections

Most cited references 23

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Angiotensin-receptor blockade versus converting-enzyme inhibition in type 2 diabetes and nephropathy.

Calum C. Bain, Sten Madsbad, Jukka Mustonen … (2004)

Few studies have directly compared the renoprotective effects of angiotensin II-receptor blockers and angiotensin-converting-enzyme (ACE) inhibitors in persons with type 2 diabetes. In this prospective, multicenter, double-blind, five-year study, we randomly assigned 250 subjects with type 2 diabetes and early nephropathy to receive either the angiotensin II-receptor blocker telmisartan (80 mg daily, in 120 subjects) or the ACE inhibitor enalapril (20 mg daily, in 130 subjects). The primary end point was the change in the glomerular filtration rate (determined by measuring the plasma clearance of iohexol) between the baseline value and the last available value during the five-year treatment period. Secondary end points included the annual changes in the glomerular filtration rate, serum creatinine level, urinary albumin excretion, and blood pressure; the rates of end-stage renal disease and cardiovascular events; and the rate of death from all causes. After five years, the change in the glomerular filtration rate was -17.5 ml per minute per 1.73 m2 (where the minus sign denotes a decrement) in the telmisartan-treated subjects, as compared with -15.0 ml per minute per 1.73 m2 in the enalapril-treated subjects; the treatment difference was thus -2.6 ml per minute per 1.73 m2 (95 percent confidence interval, -7.1 to 2.0 ml per minute per 1.73 m2)[corrected] The lower boundary of the confidence interval, in favor of enalapril, was greater than the predefined margin of -10.0 ml per minute per 1.73 m2, indicating that telmisartan was not inferior to enalapril. The effects of the two agents on the secondary end points were not significantly different after five years. Telmisartan is not inferior to enalapril in providing long-term renoprotection in persons with type 2 diabetes. These findings do not necessarily apply to persons with more advanced nephropathy, but they support the clinical equivalence of angiotensin II-receptor blockers and ACE inhibitors in persons with conditions that place them at high risk for cardiovascular events. Copyright 2004 Massachusetts Medical Society.

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Blood pressure predicts risk of developing end-stage renal disease in men and women.

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Blood pressure as a risk factor for development of end-stage renal disease has not been fully studied, particularly in women. We studied the development of end-stage renal disease from 1983 through 2000 in 98 759 subjects, 46 881 men and 51 878 women, 20 to 98 years of age, who were screened in 1983 in Okinawa, Japan. Data for all dialysis patients registered from 1983 to 2000 in Okinawa were used to identify the screened subjects in whom end-stage renal disease developed. In follow-up, 400 subjects, 231 men and 169 women, had end-stage renal disease. Age, body mass index, and adjusted relative risk for systolic and diastolic blood pressure for both men and women were measured. When these results were compared with an optimal blood pressure, the relative risk of development of end-stage renal disease for those with high-normal blood pressure and hypertension were significant in both men and women. Hypertension is a significant risk factor for development of end-stage renal disease not only in men but also in women. Control of blood pressure within normal levels should be stressed as a strategy to prevent end-stage renal disease in both men and women.

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Author and article information

Contributors

Tatsuo Shimosawa: Role: Editor

Journal

Journal ID (nlm-ta): PLoS One

Journal ID (iso-abbrev): PLoS ONE

Journal ID (publisher-id): plos

Journal ID (pmc): plosone

Title: PLoS ONE

Publisher: Public Library of Science (San Francisco, CA USA )

ISSN (Electronic): 1932-6203

Publication date (Electronic): 15 May 2017

Publication date Collection: 2017

Volume: 12

Issue: 5

Electronic Location Identifier: e0177654

Affiliations

[1 ]Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan

[2 ]Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, Taipei City, Taiwan

[3 ]Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei City, Taiwan

[4 ]Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei City, Taiwan

[5 ]Clinical Informatics & Medical Statistics Research Center, Chang Gung University, Taoyuan City, Taiwan

[6 ]Department of Internal Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu City, Taiwan

The University of Tokyo, JAPAN

Author notes

Competing Interests: The authors have declared that no competing interests exist.

Conceptualization: HYW YKT TSC KYH KLC.
Data curation: PCC CKC CJC YSP.
Formal analysis: HYW CLP JWH YSP.
Funding acquisition: HYW.
Investigation: HYW CLP.
Methodology: PCC YKT JWH.
Project administration: CJC CKC TSC.
Resources: TSC KYH KLC.
Software: HYW CLP PCC KLC.
Supervision: CJC CKC TSC KYH KLC.
Validation: YKT KYH KLC.
Visualization: HYW CLP.
Writing – original draft: HYW CLP PCC YKT KLC.
Writing – review & editing: CJC CKC JWH YSP TSC KYH.

* E-mail: kyhung@ 123456ntu.edu.tw (KYH); klchien@ 123456ntu.edu.tw (KLC)

Author information

Hon-Yen Wu http://orcid.org/0000-0003-3121-3351

Article

Publisher ID: PONE-D-17-04624

DOI: 10.1371/journal.pone.0177654

PMC ID: 5432180

PubMed ID: 28505194

SO-VID: 11596934-dc6f-431a-aa66-c272a964e39a

License:

This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

History

Date received : 5 February 2017

Date accepted : 1 May 2017

Page count

Figures: 3, Tables: 5, Pages: 16

Funding

Funded by: funder-id http://dx.doi.org/10.13039/501100004663, Ministry of Science and Technology, Taiwan;

Award ID: MOST 103-2314-B-418-003-MY2

Award Recipient :