Effects Of Angiotensin-converting Enzyme Inhibitors And Angiotensin ? Receptor Blockers On All-cause Mortality And Renal Outcomes In Patients With Diabetes And Albuminuria: A Systematic Review And Meta-analysis

Background/Aims: Whether angiotensin-converting enzyme(ACE)inhibitors or angiotensin II receptor blockers(ARB)could benefit patients with diabetes and albuminuria remains controversial.A systematic review and meta-analysis were conducted to answer this question by comparing ACE inhibitors or ARB with placebo among these patients.Methods: In this meta-analysis,electronic data sources(Medline,the Cochrane Collaboration,and EMBASE)were searched.Randomized controlled trials(RCTs)comparing ACE inhibitors or ARB with placebo in subjects with diabetes and albuminuria(defined as urinary albumin-to-creatinine ratio,UACR?30mg/g Cr)were included.Outcomes parameters were all-cause mortality,end stage renal disease(ESRD),doubling of serum creatinine levels,and cardiovascular events(CV).Result: Twenty-six RCTs(including 20 for ACE inhibitors and 6 forARB)were included,comprising 10 378 participants with diabetes and albuminuria.Compared to placebo,treatment with ACE inhibitors or ARBs did not reduce all-cause mortality or CV.For renal outcomes,ARBs significantly reduced the risk of ESRD by 23%(odds ratio 0.77,95%CI0.65-0.92),while ACE inhibitors were not associated with a decreased risk of ESRD(0.69,0.43-1.10).Both ACE inhibitors and ARBs reduced the risk of doubling of the serum creatinine level(0.60,0.39-0.91 for ACE inhibitors;0.75,0.64-0.88 for ARBs),and subgroup analyses for patients with macroalbuminuria or microalbuminuria showed similar results.Conclusions: In patients with diabetes and albuminuria,ARBs reduced risks of ESRD and doubling of the serum creatinine level.ACE inhibitors and ARBs failed to reduce all-cause mortality and CV.Based on the renoprotective effects,ARBs may be preferred for diabetic patients with albuminuria.