ACE inhibitors in chronic kidney disease (CKD)

• renin-angiotensin system blockade reduces proteinuria and retards chronic kidney disease progression independent of blood pressure lowering
  • nephroprotection reflects both hemodynamic and nonhemodynamic mechanisms that culminate in attenuation of proinflammatory and profibrotic mediators in the renal parenchyma
  • angiotensin-converting enzyme (ACE) inhibitors were originally shown to retard progression of type 1 diabetic nephropathy (1)
  • ACE inhibitors are more effective than other antihypertensives in slowing progression of nondiabetic kidney disease (2)
• a review found that the effectiveness of ACE inhibitors is similar across various baseline risks for disease progression in non-diabetic nephropathy (3)
  • however when stratified according to degree of proteinuria
    • among the subgroup of patients with proteinuria > or =500 mg/d, significant treatment effect was seen across all patients with a measurable outcome risk, including those at relatively low risk (1.7% annualized risk for progression).
    • there was no benefit of ACEI therapy among patients with proteinuria <500 mg/d, even among higher risk patients (control outcome rate 19.7%)

Reference:

• (1) Brenner B. Retarding the progression of renal disease. Kidney Int 2003;64:370–378.
• (2) Jaber BL et al. Progression of chronic kidney disease: Can it be prevented or arrested? The American Journal of Medicine 2005; 118 (12): 1323-1330.
• (3) Kent DM et al. Progression risk, urinary protein excretion, and treatment effects of angiotensin-converting enzyme inhibitors in nondiabetic kidney disease.J Am Soc Nephrol. 2007 Jun;18(6):1959-65