***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
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    Input: Clinical practice guidelines recommend blockers of the renin-angiotensin system alone or in combination with other agents to reduce blood pressure and albuminuria in patients with type 2 diabetes .  Dihydropyridine calcium channel blockers , however , may lower blood pressure but not albuminuria in these patients . Here we tested the hypothesis that combining an ACE inhibitor with either a thiazide diuretic or a calcium channel blocker will cause similar reductions in blood pressure and albuminuria in hypertensive type 2 diabetics . We conducted a double blind r and omized controlled trial on 332 hypertensive , albuminuric type 2 diabetic patients treated with benazepril with either amlodipine or hydrochlorothiazide for 1 year . The trial employed a non-inferiority design . Both combinations significantly reduced the urinary albumin to creatinine ratio and sitting blood pressure of the entire cohort . The percentage of patients progressing to overt proteinuria was similar for both groups . When we examined patients who had only microalbuminuria and hypertension we found that a larger percentage of the diuretic and ACE inhibitor normalized their albuminuria . We conclude that initial treatment using benzaepril with a diuretic result ed in a greater reduction in albuminuria compared to the group of ACE inhibitor and calcium channel blocker . In contrast , blood pressure reduction , particularly the diastolic component , favored the combination with amilodipine . The dissociation between reductions in blood pressure and albuminuria may be related to factors other than blood pressure BACKGROUND Few studies have directly compared the renoprotective effects of angiotensin II-receptor blockers and angiotensin-converting-enzyme ( ACE ) inhibitors in persons with type 2 diabetes . METHODS In this prospect i ve , multicenter , double-blind , five-year study , we r and omly assigned 250 subjects with type 2 diabetes and early nephropathy to receive either the angiotensin II-receptor blocker telmisartan ( 80 mg daily , in 120 subjects ) or the ACE inhibitor enalapril ( 20 mg daily , in 130 subjects ) . The primary end point was the change in the glomerular filtration rate ( determined by measuring the plasma clearance of iohexol ) between the baseline value and the last available value during the five-year treatment period . Secondary end points included the annual changes in the glomerular filtration rate , serum creatinine level , urinary albumin excretion , and blood pressure ; the rates of end-stage renal disease and cardiovascular events ; and the rate of death from all causes . RESULTS After five years , the change in the glomerular filtration rate was -17.5 ml per minute per 1.73 m2 ( where the minus sign denotes a decrement ) in the telmisartan-treated subjects , as compared with -15.0 ml per minute per 1.73 m2 in the enalapril-treated subjects ; the treatment difference was thus -2.6 ml per minute per 1.73 m2 ( 95 percent confidence interval , -7.1 to 2.0 ml per minute per 1.73 m2)[corrected ] The lower boundary of the confidence interval , in favor of enalapril , was greater than the predefined margin of -10.0 ml per minute per 1.73 m2 , indicating that telmisartan was not inferior to enalapril . The effects of the two agents on the secondary end points were not significantly different after five years . CONCLUSIONS Telmisartan is not inferior to enalapril in providing long-term renoprotection in persons with type 2 diabetes . These findings do not necessarily apply to persons with more advanced nephropathy , but they support the clinical equivalence of angiotensin II-receptor blockers and ACE inhibitors in persons with conditions that place them at high risk for cardiovascular events BACKGROUND Nephropathy and retinopathy remain important complications of type 1 diabetes . It is unclear whether their progression is slowed by early administration of drugs that block the renin-angiotensin system . METHODS We conducted a multicenter , controlled trial involving 285 normotensive patients with type 1 diabetes and normoalbuminuria and who were r and omly assigned to receive losartan ( 100 mg daily )  , enalapril  ( 20 mg daily ) , or placebo and followed for 5 years . The primary end point was a change in the fraction of glomerular volume occupied by mesangium in kidney-biopsy specimens . The retinopathy end point was a progression on a retinopathy severity scale of two steps or more . Intention-to-treat analysis was performed with the use of linear regression and logistic-regression models . RESULTS A total of 90 % and 82 % of patients had complete renal-biopsy and retinopathy data , respectively .  Change in mesangial fractional volume per glomerulus over the 5-year period did not differ significantly between the placebo group ( 0.016 units ) and the enalapril group ( 0.005 , P=0.38 ) or the losartan group ( 0.026 , P=0.26 ) , nor were there significant treatment benefits for other biopsy-assessed renal structural variables . The 5-year cumulative incidence of microalbuminuria was 6 % in the placebo group ; the incidence was higher with losartan ( 17 % , P=0.01 by the log-rank test ) but not with enalapril ( 4 % , P=0.96 by the log-rank test ) . As compared with placebo , the odds of retinopathy progression by two steps or more was reduced by 65 % with enalapril ( odds ratio , 0.35 ; 95 % confidence interval [ CI ] , 0.14 to 0.85 ) and by 70 % with losartan ( odds ratio , 0.30 ; 95 % CI , 0.12 to 0.73 ) , independently of changes in blood pressure . There were three biopsy-related serious adverse events that completely resolved . Chronic cough occurred in 12 patients receiving enalapril , 6 receiving losartan , and 4 receiving placebo . CONCLUSIONS Early blockade of the renin-angiotensin system in patients with type 1 diabetes did not slow nephropathy progression but slowed the progression of retinopathy . ( Clinical Trials.gov number , NCT00143949 . Recent studies utilizing converting enzyme inhibitors ( CEI ) in diabetic rats document reductions in both renal hypertrophy and albuminuria . Four separate clinical studies in normotensive patients with diabetes demonstrate reduction of microalbuminuria with CEIs independent of blood pressure reduction . The present pilot study examines the results of reducing an elevated glomerular filtration rate on changes in renal size and microalbuminuria in normotensive , hyperfiltering insulin-dependent diabetic ( IDDM ) patients . Fifteen IDDM patients were r and omized to either placebo or the CEI , lisinopril . Dosage of lisinopril was titrated over 3 months to reduce glomerular filtration rate ( GFR ) to < or = 2.33 mL/sec . Evaluation at 18 months demonstrated the lisinopril group had a marked reduction in renal size ( 16.9 + /- 1.1 , baseline versus 12.8 + /- 0.9 cm , 18 months ; p < 0.05 ) and microalbuminuria ( 92 + /- 11 micrograms/min , baseline versus 23 + /- 26 micrograms/min , 18 months ; p < 0.05 ) . No change in renal size was noted in the placebo group ( 15.4 + /- 0.8 , baseline versus 14.9 + /- 0.7 cm , 18 months ; NS ) and albuminuria increased ( 118 + /- 15 micrograms/min , baseline versus 293 + /- 32 micrograms/min , 18 months ; p < 0.05 ) . Mean arterial pressure at 18 months was significantly lower in the lisinopril group compared to placebo ( 102 + /- 4 , placebo versus 87 + /- 6 mm Hg , CEI , p < 0.05 ) . This study supports previous animal studies that document reductions in both microalbuminuria and renal size by a CEI . The overall impact of these findings on preservation of renal function can not be assessed , however , in this short-term study PURPOSE To determine whether angiotensin-converting enzyme ( ACE ) inhibition with captopril reduces the progression of microalbuminuria to overt proteinuria in normotensive patients with insulin-dependent diabetes mellitus ( IDDM ) . PATIENTS AND METHODS This study was a prospect i ve r and omized , double-blind , placebo-controlled trial involving 26 centers in the United States and Canada . One hundred forty-three subjects , 14 to 57 years of age , with IDDM for 4 to 33 years , blood pressure < 140/90 mm Hg in the absence of antihypertensive therapy , and persistent albumin excretion 20 to 200 micrograms/min were r and omized to double-blind treatment with captopril 50 mg or placebo BID . Albumin excretion rate ( AER ) , blood pressure , and glycohemoglobin were determined every 3 months , and creatinine clearance ( CrCl ) and urea excretion were measured every 6 months . RESULTS Within 24 months , 6.0 % ( 4/67 ) of captopril-treated subjects and 18.6 % ( 13/70 ) of placebo-treated subjects progressed to clinical proteinuria , defined as AER > 200 micrograms/min and at least 30 % above baseline ( risk reduction = 67.8 % , P = 0.037 ) . AER increased at an annual rate of 11.8 % ( 95 % confidence interval [ CI ] -3.3 % to 29.1 % ) in the placebo group , while it declined by 17.9 % ( CI -29.6 % to -4.3 % ) in the captopril group ( P = 0.004 ) . CrCl decreased by 4.9 mL/min per 1.73 m2 per year in the placebo group , while it remained stable in the captopril group ( 0.9 mL/min per 1.73 m2 per year , P = 0.039 between groups ) . Ten subjects required treatment for hypertension ; 8 in the placebo group and 2 in the captopril group . There was little correlation between the 24-month changes in mean arterial blood pressure and AER in either group . Glycohemoglobin and urinary urea excretion did not differ between groups . CONCLUSIONS After 24 months of therapy with captopril , compared with placebo , normotensive subjects with IDDM experienced significantly less progression of microalbuminuria to clinical proteinuria , reduced albumin excretion , and preserved CrCl rate . The ACE inhibitor , captopril , was well tolerated Mixed treatment comparison ( MTC ) meta- analysis is a generalization of st and ard pairwise meta- analysis for A vs B trials , to data structures that include , for example , A vs B , B vs C , and A vs C trials . There are two roles for MTC : one is to strengthen inference concerning the relative efficacy of two treatments , by including both ' direct ' and ' indirect ' comparisons . The other is to facilitate simultaneous inference regarding all treatments , in order for example to select the best treatment . In this paper , we present a range of Bayesian hierarchical models using the Markov chain Monte Carlo software WinBUGS . These are multivariate r and om effects models that allow for variation in true treatment effects across trials . We consider models where the between-trials variance is homogeneous across treatment comparisons as well as heterogeneous variance models . We also compare models with fixed ( unconstrained ) baseline study effects with models with r and om baselines drawn from a common distribution . These models are applied to an illustrative data set and posterior parameter distributions are compared . We discuss model critique and model selection , illustrating the role of Bayesian deviance analysis , and node-based model criticism . The assumptions underlying the MTC models and their parameterization are also discussed OBJECTIVES --To compare the efficacy , safety , and tolerance of enalapril and nifedipine in hypertensive patients with non-insulin dependent diabetes . DESIGN --One year double blind follow up of patients r and omly allocated to either enalapril or nifedipine with matching placebos for the alternative drug . SETTING --Metabolic Investigation Unit , Hong Kong . SUBJECTS--102 patients were r and omised : 52 to nifedipine and 50 to enalapril . At baseline 44 patients had normoalbuminuria , 36 microalbuminuria , and 22 macroalbuminuria . MAIN OUTCOME MEASURES --Blood pressure , albuminuria , and parameters of renal function and glycaemic control . RESULTS --In patients who completed one year 's treatment the median dose required by the nifedipine group ( n = 49 ) was 60 mg/day ; seven ( 14 % ) required additional diuretics . Of 41 patients given enalapril , 37 required the maximum dose ( 40 mg/day ) and 27 ( 76 % ) required diuretics . At one year mean arterial blood pressures were similar in both groups . Albuminuria fell by 54 % in the enalapril group and 11 % in the nifedipine group ( p = 0.006 ) . Fractional albumin clearance ratio fell by 47 % in the enalapril group and increased by 3 % in the nifedipine group ( p = 
    Output:
    
Comparisons among all treatments showed no statistical significance in the outcome of dialysis .
Although the beneficial effects of ACE inhibitors compared with ARBs did not reach statistical significance , ACE inhibitors consistently showed higher probabilities of being in the superior ranking positions among all three outcomes .
Our analyses show the renoprotective effects and superiority of using ACE inhibitors in patients with diabetes , and available evidence is not able to show a better effect for ARBs compared with ACE inhibitors .
Considering the cost of drugs , our findings support the use of ACE inhibitors as the first line antihypertensive agent in patients with diabetes .
Calcium channel blockers might be the preferred treatment in combination with ACE inhibitors if adequate blood pressure control can not be achieved by ACE inhibitors alone