Angiotensin receptor neprilysin inhibitors and renal outcomes in patients with heart failure: a systematic review and meta-analysis.

In 30 seconds

This systematic review and meta-analysis examined renal outcomes with angiotensin receptor neprilysin inhibitors (ARNi) versus renin-angiotensin-aldosterone system inhibitors (RAASi) alone in patients with heart failure. Across 15 studies involving 31 574 individuals, ARNi were associated with fewer worsening renal function events (relative risk 0.83, 95% confidence interval 0.71-0.96; P = .01), corresponding to 13 fewer events per 1000 patients. ARNi were also associated with lower risks of substantial eGFR decline and acute kidney injury, but with more symptomatic hypotension; hyperkalaemia did not differ significantly.

Key findings

• Worsening renal function events were lower with ARNi than RAASi alone (relative risk 0.83, 95% confidence interval 0.71-0.96; P = .01), or 13 fewer events per 1000 patients.
• ARNi were associated with lower risk of >50% decline in eGFR (relative risk 0.61, 95% CI 0.47-0.78; P < .001).
• Acute kidney injury was less frequent with ARNi (relative risk 0.82, 95% CI 0.69-0.97; P = .024), while symptomatic hypotension was more frequent (RR: 1.54, CI 95%: 1.35-1.76; I2 = 69%; P < .001).
• There was no significant difference between groups in hyperkalaemia >5.5 mmol/L.

Why it matters

Renal effects are an important consideration when selecting and monitoring heart failure therapy. These pooled trial findings suggest ARNi may be associated with fewer adverse renal outcomes than RAASi alone, while the higher incidence of symptomatic hypotension highlights a competing safety outcome. The results help frame the balance of renal and haemodynamic effects without establishing that every patient will experience the same benefit or risk.

What to keep in mind

The abstract does not report follow-up duration or provide details on variation among included trials beyond the reported heterogeneity for symptomatic hypotension.