A LARGE real-world study suggests that renin-angiotensin-aldosterone system inhibitors (RAASi) may be more effective than calcium channel blockers (CCB) as first-line antihypertensive therapy in children with chronic kidney disease (CKD), offering improved kidney outcomes and better blood pressure control.
Hypertension is a key modifiable driver of CKD progression, yet comparative trials of commonly used antihypertensive agents in paediatric populations have been limited. To address this gap, researchers conducted a comparative-effectiveness study using a “target trial emulation” approach, analysing electronic health record data from the PRESERVE cohort across 13 institutions in five PCORnet networks.
The study included 2,762 children and adolescents aged 2-20 years with stage 2-4 CKD and hypertension who initiated treatment with either RAASi (n=1,757) or CCB (n=1,005) between 2009 and 2020. Propensity score weighting was used to balance baseline characteristics, including CKD severity, comorbidities, and blood pressure control.
RAAS Inhibitors Linked to Lower Kidney Failure Risk
Over two years of follow-up, RAASi treatment was associated with a significantly lower risk of progression to kidney replacement therapy compared with CCB (adjusted hazard ratio [aHR] 0.58; 95% CI 0.40–0.84). RAASi was also linked to a reduced risk of a composite outcome comprising kidney replacement therapy, ≥50% decline in estimated glomerular filtration rate (eGFR), or eGFR <15 mL/min/1.73 m² (aHR 0.67; 95% CI 0.53–0.83).
In addition to improved renal outcomes, RAASi demonstrated superior blood pressure control. Patients receiving RAASi spent less time with systolic blood pressure above the 90th percentile compared with those on CCB (29% vs 39%).
Evidence Supports Guideline-Preferred First-Line Therapy
The findings provide important real-world evidence supporting current guideline preferences for RAAS inhibition in paediatric CKD. By emulating a pragmatic clinical trial using observational data, the study offers robust comparative insights where randomised trials are lacking.
The authors conclude that RAASi should be considered the preferred first-line antihypertensive strategy in children with CKD, given its association with slower disease progression and improved blood pressure control. Further research may help refine treatment strategies and explore long-term outcomes beyond the two-year follow-up period.
Reference
Denburg M et al. Comparative Effectiveness of Antihypertensive Medications in Children With Chronic Kidney Disease. Jama Pediatr. 2026;doi: 10.1001/jamapediatrics.2026.0207
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