A Cochrane review included 26 studies with a total of 61 264 subjects. Angiotensin-converting enzyme inhibitors (ACEi) reduced the risk of new onset of microalbuminuria, macroalbuminuria or both when compared to placebo (RR 0.71, 95% CI 0.56 to 0.89; 8 studies, n=11 906), with similar benefits in people with and without hypertension (P = 0.74), and when compared to calcium channel blockers (RR 0.60, 95% CI 0.42 to 0.85; 5 studies, n=1 253). ACEi reduced the risk of death when compared to placebo (RR 0.84, 95% CI 0.73 to 0.97; 6 studies, n=11 350).
No effect was observed for angiotensin receptor blockers (ARB) when compared to placebo for new microalbuminuria, macroalbuminuria or both (RR 0.90, 95% CI 0.68 to 1.19; 5 studies, n=7 653) or death (RR 1.12, 95% CI 0.88 to 1.41; 5 studies, n=7 653); however, meta-regression suggested possible benefits from ARB for preventing kidney disease in high risk patients. There was a trend towards benefit from use of combined ACEi and ARB for prevention of diabetic kidney disease compared with ACEi alone (RR 0.88, 95% CI 0.78 to 1.00; 2 studies, n=4 171).
The risk of cough was significantly increased with ACEi when compared to placebo (RR 1.84, 95% CI 1.24 to 2.72; 6 studies, n=11 791), however there was no significant difference in the risk of headache or hyperkalaemia. There was no significant difference in the risk of cough, headache or hyperkalaemia when ARB was compared to placebo.
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