RAAS Inhibitors Best CCBs at Improving Outcomes in Pediatric CKD: JAMA
USA: Renin-angiotensin-aldosterone system (RAAS) inhibitors are associated with better outcomes in children with chronic kidney disease (CKD) compared to calcium channel blockers (CCBs), including a lower likelihood of progression to dialysis or kidney transplantation and fewer overall adverse events.
In a new study published in JAMA Pediatrics, Michelle R. Denburg from the Children’s Hospital of Philadelphia and colleagues evaluated the real-world effectiveness of the two most commonly used first-line antihypertensive therapies in pediatric CKD—RAAS inhibition and calcium channel blockade. Hypertension is a key modifiable contributor to declining kidney function in CKD, yet direct comparative trials in children have remained limited.
To address this gap, the investigators conducted a comparative-effectiveness study using a target trial emulation framework. They analyzed electronic health record data from the PRESERVE study, spanning January 2009 to December 2020, and including 13 healthcare institutions across five clinical research networks. The study population comprised 2,762 children and adolescents aged 2 to 20.9 years with stage 2 to 4 CKD who had elevated systolic blood pressure or a diagnosis of hypertension and were newly started on either RAAS inhibitors or CCBs.
Among the participants, 1,757 initiated RAAS inhibitor therapy, while 1,005 received calcium channel blockers. The researchers applied advanced statistical methods, including propensity score weighting, to ensure balanced comparison between the two groups by accounting for demographic factors, disease severity, comorbidities, and treatment patterns.
The primary outcome assessed was progression to kidney replacement therapy—defined as dialysis or kidney transplantation—within two years.
The study led to the following findings:
- Children receiving RAAS inhibitors had a significantly lower risk of progressing to kidney replacement therapy compared to those treated with calcium channel blockers.
- RAAS inhibition was linked to a 42% reduction in the risk of requiring dialysis or kidney transplantation.
- RAAS inhibitors also showed a protective effect when broader outcomes were considered, including a major decline in kidney function or a very low estimated glomerular filtration rate.
- Blood pressure control was more effective in the RAAS inhibitor group, with less time spent above the 90th percentile for systolic blood pressure compared to the calcium channel blocker group.
Overall, the findings highlight the clinical advantage of RAAS inhibition in slowing CKD progression in pediatric patients. The study provides important real-world evidence supporting the preferential use of RAAS inhibitors as first-line antihypertensive therapy in this population, particularly given their dual benefit in improving blood pressure control and preserving kidney function.
Reference:
Denburg MR, Goodwin Davies AJ, Maltenfort MG, et al. Comparative Effectiveness of Antihypertensive Medications in Children With Chronic Kidney Disease. JAMA Pediatr. Published online March 16, 2026. doi:10.1001/jamapediatrics.2026.0207
Next Story