Impact of continuous positive airway pressure therapy on renin–angiotensin–aldosterone system in obstructive sleep apnea: an updated systematic review and meta-analysis

Loh, Huai Heng and Kang, Waye Hann and Anne, Yee and Anselm, Su Ting and Yong, Mei Ching and Asri, Said (2026) Impact of continuous positive airway pressure therapy on renin–angiotensin–aldosterone system in obstructive sleep apnea: an updated systematic review and meta-analysis. Sleep and Breathing, 30 (143). pp. 1-13. ISSN 1522-1709

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Abstract

Purpose While continuous positive airway pressure (CPAP) reduces cardiovascular risk in obstructive sleep apnea (OSA), its effects on renin–angiotensin–aldosterone system (RAAS) modulation remain controversial. This meta-analysis investigates CPAP's differential impacts on RAAS components and identifies responsive patient subgroups. Methods Sixteen studies were included in the systematic review and eight (231 patients) in the meta-analysis. Primary outcomes included plasma aldosterone concentration (PAC), plasma renin activity (PRA), and angiotensin II (AngII) changes. Subgroup analyses examined age, BMI, and CPAP duration thresholds, with meta-regression assessing moderating factors. Results CPAP significantly reduced PAC (d+of -0.72, 95% CI -1.39 to -0.05, p=0.036), though statistical significance was attenuated in adjusted models, and improved daytime hemodynamics: systolic BP (d+-0.81), diastolic BP (d+-1.30), and heart rate (d+-1.61). Notably, patients<50 years showed marked PAC reduction (d+-1.12, 95% CI -1.88 to -0.35), as did those with CPAP adherence≥3 months (d+-0.88, 95% CI -1.86 to 0.09). No significant changes occurred in PRA (p=0.917), plasma renin concentration (p=0.463), or AngII (p=0.058) in the overall cohort. Meta-regression revealed no significant associations between age, BMI, or CPAP duration and RAAS changes (all p>0.05). Conclusion CPAP demonstrates selective RAAS modulation – significantly lowering PAC – alongside pronounced hemodynamic benefits, even though overall renin and AngII levels did not change significantly. Younger patients (<50 years) and those maintaining≥3 months therapy show aldosterone responsiveness, suggesting duration-dependent physiological effects. These findings highlight CPAP's potential role in targeted RAAS modulation and underscore the need for personalized treatment strategies in OSA management.

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