TABLE 5.
Advantages and disadvantages of DRI, ACEIs, and ARBs in CKD.
| Advantages | Disadvantages | |
|---|---|---|
| DRI | • Decreases systolic and diastolic BP. | • May be associated with symptomatic hypotension |
| • Causes a progressive decrease in urinary albumin-to-creatinine ratio. | • Associated with hyperkalemia | |
| • May reduce sympathetic hyperactivity in patients with CKD. | • Monotherapy of aliskiren in CKD is not commonly practiced and is less investigated, yielding inconclusive results. | |
| • Inhibits brain natriuretic peptide, high-sensitivity C-reactive protein, and diacron-reactive oxygen metabolite. | • Combination treatments are more favored | |
| • Decreases urinary albumin/creatinine ratios in IgA nephropathy patients. | • Has no additional benefit for renoprotection or increase in adverse events in non-diabetic CKD patients, except for more hyperkalemia events | |
| • Mitigates oxidative stress and may improve the functional status of tubules. | • Is expensive | |
| ACEIs | • Reduce the systemic vascular resistance, thereby decreasing hypertension. | • Lead to a compensatory rise in renin levels due to loss of negative feedback inhibition of renin |
| • Reduce the incidence of progression to overt proteinuria. | • Have minimal effect on local Ang II production | |
| • Reduce the rate of GFR decline to levels similar to those associated with normal aging. | • Have been associated with instances of acute liver injury, acute kidney injury, and acute renal failure. | |
| • Significantly slow the rate of decline in creatinine clearance. | • Can cause an idiosyncratic reaction of ACEI-induced cough. | |
| • Reduce the markers of vascular microinflammation. | • In the diabetic population with renal transplants, ACEIs showed no association with improved clinical outcomes. | |
| • Increase the restoration of normoalbuminuria. | • ACEIs seem to have no benefit or no adversities at advanced stages | |
| • Are more effective in decelerating the progression to end-stage renal disease in non-diabetic patients presenting nephropathy when compared to other antihypertensives | • Discontinuation of ACEIs is common, especially in patients with lower eGFR. | |
| ARBs | • Inhibit the vasoconstricting activity on smooth muscles, hence lowering blood pressure. | • Can raise the levels of renin, angiotensin I, and angiotensin II as a result of feedback inhibition. |
| • The BP-lowering efficacy of ARBs is similar or numerically higher compared to ACE inhibitors when using ambulatory BP measurements. A numerically higher reduction in office systolic BP with ARBs is reported compared to ACE inhibitors. | • Can cause hypotension and/or renal failure in patients with heart failure presenting hypotension or bilateral renal artery stenosis | |
| • Although statistically insignificant, a better decrease in left ventricular mass index with ARBs is observed (13%) than with ACE inhibitors by 10%. | • ARBs are better tolerated than angiotensin-converting enzyme inhibitors | |
| • Have a lower rate of discontinuation |