Kidney Week

Abstract: TH-PO0752

Comparative Adverse Effects of Angiotensin Receptor-Neprilysin Inhibitors and ACE Inhibitors/ARBs on Kidney and Hemodynamic Outcomes in Chronic Heart Failure: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Session Information

• AKI: Critical Care, CKRT, Cardiorenal Syndromes, and Clinical Outcomes
  October 22, 2026 | Location: Exhibit Hall A, Convention Center
  Abstract Time: 10:00 AM - 12:00 PM

Category: Acute Kidney Injury

• 102 AKI: Clinical, Outcomes, and Trials

Authors

• Deepan, Natee, Chiang Mai University, Chiang Mai, Thailand

Natee Deepan, MD

• Ansusinha, Parinda, Srinakharinwirot University, Bangkok, Thailand

Parinda Ansusinha, MD

• Chalermchat, Thanasin, Mahidol University Faculty of Medicine Siriraj Hospital, Bangkok, Thailand

Thanasin Chalermchat

• Asawaroekwisoot, Thanin, Division of Nephrology, Hypertension and Kidney Transplantation , Department of Medicine, University of California Irvine, Irvine, California, United States

Thanin Asawaroekwisoot, MD

• Chamnarnphol, Natanon, Mahidol University Faculty of Medicine Siriraj Hospital, Bangkok, Thailand

Natanon Chamnarnphol, MD

• Kitlertbanchong, Nitchanan, Mahidol University Faculty of Medicine Siriraj Hospital, Bangkok, Thailand

Nitchanan Kitlertbanchong, MD

• Tangprasittichok, Nathasith, Division of Nephrology, Hypertension and Kidney Transplantation , Department of Medicine, University of California Irvine, Irvine, California, United States

Nathasith Tangprasittichok, MD

• Ngamvirojcharoen, Boonyasit, Mahidol University Faculty of Medicine Siriraj Hospital, Bangkok, Thailand

Boonyasit Ngamvirojcharoen, MD

• Siwawut, Katanyu, Mahidol University Faculty of Medicine Siriraj Hospital, Bangkok, Thailand

Katanyu Siwawut, MD

• Chongthanadon, Brandon, Mahidol University Faculty of Medicine Siriraj Hospital, Bangkok, Thailand

Brandon Chongthanadon, MD

• Noree, Wanprapit, Division of Nephrology, Hypertension and Kidney Transplantation , Department of Medicine, University of California Irvine, Irvine, California, United States

Wanprapit Noree, MD

• Chuenchaem, Urairat, Division of Nephrology, Hypertension and Kidney Transplantation , Department of Medicine, University of California Irvine, Irvine, California, United States

Urairat Chuenchaem, MD

• Buadee, Settawut, Mahidol University Faculty of Medicine Siriraj Hospital, Bangkok, Thailand

Settawut Buadee, MD

• Kasebuthtaweewat, Yodsaphong, Mahidol University Faculty of Medicine Siriraj Hospital, Bangkok, Thailand

Yodsaphong Kasebuthtaweewat, MD

• Vutthikraivit, Possawat, Division of Nephrology, Hypertension and Kidney Transplantation , Department of Medicine, University of California Irvine, Irvine, California, United States

Possawat Vutthikraivit, MD

• Bunyawannukul, Issaree, Division of Nephrology, Hypertension and Kidney Transplantation , Department of Medicine, University of California Irvine, Irvine, California, United States

Issaree Bunyawannukul, MD

• Tantisattamo, Ekamol, Division of Nephrology, Hypertension and Kidney Transplantation , Department of Medicine, University of California Irvine, Irvine, United States

Ekamol Tantisattamo, MD, MPH, FASN

Background

Angiotensin receptor–neprilysin inhibitors (ARNIs) reduce hospitalizations and mortality compared with ACE inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) in chronic heart failure. Although renal injury and hemodynamic instability contribute substantially to morbidity in this population, the adverse effect of ARNIs on renal outcomes compared to ACEIs and ARBs is unclear.

Methods

We searched ClinicalTrials.gov, Embase, and PubMed from database inception to April 2025 for randomized controlled trials (RCTs) comparing ARNIs with ACEIs/ARBs in patients with heart failure. The primary outcome was acute kidney injury (AKI); secondary outcomes included chronic kidney disease (CKD), hypokalemia, hyperkalemia, hyperuricemia, hyperglycemia and hypotension. Random-effects model estimated risk ratios (RR) with 95% confidence intervals (CI).

Results

Seven RCTs comprising 15,737 patients were included; 65% were male, with similar baseline characteristics between ARNIs and ACEIs/ARBs groups, including mean age (67.8 vs 67.8 years) and LVEF in HFrEF (29.1% vs 29.3%) and HFpEF (57.0% vs 57.2%). Median follow-up ranged from 12 to 38 months. Compared to ACEIs/ARBs group, ARNIs group had no significant difference in AKI (RR 1.01, 95% CI: 0.87–1.17; Fig 1), hyperkalemia (RR 1.07, 95% CI: 0.50–2.29), and hypokalemia (RR 1.03, 95% CI: 0.59–1.7). While CKD appears lower in ARNIs group, there is no significant difference (RR 0.65, 95% CI: 0.34–1.23). There were no difference in metabolic outcomes, including hyperuricemia (RR 1.41, 95% CI: 0.46–4.34) and hyperglycemia (RR 0.95, 95% CI: 0.46–1.96). On hemodynamic outcome, ARNIs exhibited significantly higher risk of hypotension compared to ACEIs/ARBs group (RR 1.45, 95% CI: 1.30–1.62).

Conclusion

ARNIs and ACEIs/ARBs showed comparable adverse effects on AKI, CKD, dyskalemia, and metabolic profiles in patients with chronic heart failure, while ARNIs was associated with a higher risk of hypotension.

Forest plot comparing acute kidney injury (AKI) risk between ARNIs and ACEI/ARB.