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Evidence summaries

Antihypertensive Treatment for Kidney Transplant Recipients

Calcium channel blockers as blood pressure medication for kidney transplant patients appear to reduce all-cause death and graft loss compared to placebo. Angiotensin converting enzyme inhibitors and angiotensin II receptor blockers might possibly not have effect on death or graft loss. Level of evidence: "C"

A Cochrane review [Abstract] 1 included 97 studies with a total of 8 706 subjects; 29 studies (n=2262) compared calcium channel blockers (CCB) to placebo/no treatment; 10 studies (n=445) compared angiotensin converting enzyme inhibitors (ACEi) to placebo/no treatment, and 7 studies (n=405) compared CCB to ACEi. Other drug comparisons were in small numbers of participants and studies.

Calcium channel blockers (CCB) compared to placebo/no treatment (plus additional agents in either arm as required) reduced all-cause death (RR 0.83, 95% CI 0.72 to 0.95; 23 studies, n=3327; I²=0%; moderate certainty evidence) and graft loss (RR 0.84, 95% CI 0.75 to 0.95; 24 studies, n=3577; I² = 0%; moderate certainty evidence). There was little or no difference to estimated glomerular filtration rate (eGFR) and acute rejection.

Compared to placebo or standard care alone angiotensin converting enzyme inhibitors (ACEi) had little or no difference to all-cause death (RR 1.13, 95% CI 0.58 to 2.21; I7 studies, n=702; I²=0%; low certainty evidence), graft loss (RR 0.75, 95% CI 0.49 to 1.13; 6 studies, n=718 participants; I²=0%; low certainty evidence), eGFR, and acute rejection.

Compared to placebo or standard care alone, angiotensin receptor blockers (ARB) may had little or no difference to all-cause death (RR 0.69, 95% CI 0.36 to 1.31; 6 studies, n=1041; I²=0%; low certainty evidence), eGRF (MD -1.91 mL/min/1.73 m2, 95% CI -6.20 to 2.38; 5 studies, n=300; I²=57%; low certainty evidence), and acute rejection (RR 1.00, 95% CI 0.44 to 2.29; 4 studies, n=323; I²=0%; low certainty evidence).

A meta-analysis 2 assessing renin-angiotensin system inhibitors on survival in kidney transplant recipients included 9 RCTs and 15 cohort studies with 54 096 patients. ACEI/ARB was associated with decreased risks of patient death (RR 0.64; 95% CI 0.49 to 0.84; 14 trials) and graft loss (RR 0.59; 95% CI 0.47 to 0.74; 16 trials) compared with controls. Subgroup analysis of the cohorts revealed significantly reduced patient death (RR 0.61; 95% CI 0.50 to 0.74, 6 trials) and graft loss (RR 0.58; 95% 0.46 to 0.73; 12 trials), but this was not seen in RCTs (patient survival RR 0.84, 95% CI 0.39 to 1.81, 8 RCTs; graft survival: RR 0.70, 95% CI 0.17 to 2.79; 4 RCTs).

    References

    • Natale P, Mooi PK, Palmer SC, et al. Antihypertensive treatment for kidney transplant recipients. Cochrane Database Syst Rev 2024;7(7):CD003598. [PubMed]
    • Jiang YM, Song TR, Qiu Y et al. Effect of renin-angiotensin system inhibitors on survival in kidney transplant recipients: A systematic review and meta-analysis. Kaohsiung J Med Sci 2018;34(1):1-13. [PubMed]

Primary/Secondary Keywords