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Angiotensin-Receptor Blockers for Microalbuminuria

ARBs didn't prevent adverse renal outcomes in patients with cardiovascular disease or diabetes.

The effect of angiotensin-receptor blockers (ARBs) on renal outcomes among patients at high vascular risk but without overt diabetic nephropathy and among normoalbuminuric patients with diabetes is unknown. In two reports, researchers examined the effects of ARBs in these groups.

In a 5-year industry-sponsored international randomized trial, investigators compared telmisartan (Micardis) with placebo in 5927 adults (mean age, 67) who could not tolerate angiotensin-converting–enzyme inhibitors. All participants had cardiovascular disease or diabetes and end-organ damage but no macroalbuminuria or heart failure. No significant difference was seen in the combined outcome of serum creatinine doubling or requisite dialysis; in fact, doubling of creatinine levels and decreases from baseline in glomerular filtration rate were significantly more common with telmisartan than with placebo.

In another report, investigators presented results of three 5-year international industry-sponsored randomized trials of candesartan (Atacand): Two trials involved 3326 patients (age, <55) with type 1 diabetes (1 trial each for patients with and without retinopathy) and one trial involved 1905 patients (age, <75) with type 2 diabetes. Subjects were normotensive (people with type 2 diabetes could have controlled hypertension) and normoalbuminuric. Candesartan did not lower risk for developing microalbuminuria in any of the trials.

Comment: These trials do not support angiotensin-receptor blockade to prevent renal disease among people with vascular disease or diabetes and end-organ damage or to prevent microalbuminuria among those with diabetes and no macrovascular disease. An editorialist reminds us that ACE inhibitors do prevent microalbuminuria in people with diabetes who are at high risk for vascular disease.

— Richard Saitz, MD, MPH, FACP, FASAM

Published in Journal Watch General Medicine September 24, 2009

Citation(s):

Mann JFE et al. Effect of telmisartan on renal outcomes: A randomized trial. Ann Intern Med 2009 Jul 7; 151:1.

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• Medline abstract (Free)

Bilous R et al. Effect of candesartan on microalbuminuria and albumin excretion rate in diabetes: Three randomized trials. Ann Intern Med 2009 Jul 7; 151:11.

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• Medline abstract (Free)

Parfrey PS. Angiotensin-receptor blockers in the prevention or treatment of microalbuminuria. Ann Intern Med 2009 Jul 7; 151:63.

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• Medline abstract (Free)

Reader Remarks:

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• ARBs for micoalbuminuria
  Y Y MIMBULU, Public hospital, 17 Oct 2009 4:16 AM EST
  Quite a wonderful report in the Ann Intern Med cited above.
  
  Still one would want to know the possibilities left... [more]