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題 名 | Renoprotective Effect of Renin-Angiotensin System Inhibition in Chronic Kidney Disease: A Retrospective Analysis=血管張力素轉換酶抑制劑和血管張力素接受器阻斷劑在慢性腎臟疾病的保護角色 |
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作 者 | 林妏娟; 高雅慧; 程盟夫; 王明誠; 黃建鐘; | 書刊名 | 臺灣腎臟醫學會雜誌 |
卷 期 | 16:3 2002.09[民91.09] |
頁 次 | 頁101-107+138 |
分類號 | 415.74 |
關鍵詞 | 慢性腎臟疾病; 末期腎病; 血管張力素轉換酶抑制劑; 血管張力素接受器阻斷劑; 血壓; 腎臟保護; Chronic kidney disease; CKD; End-stage renal disease; ESRD; Angiotensin-converting enzyme inhibitors; ACEIs; Angiotensin Ⅱ type 1 receptor blockers; ARBs; Blood pressure; BP; Renoprotection; |
語 文 | 英文(English) |
中文摘要 | 慢性腎臟疾病(Chronic kidney disease, CKD)是指各種腎病的腎臟傷害或腎功能下降已持續三個月以上,多睥的患者會逐漸進展到末期腎病(end-stage renal disease, ESRD)。據統計,全世界ESRD的發生率和盛行率持續上揚,且相關的醫療支出龐大。為延緩腎臟疾病的進展,須針對疾病的惡化機轉給予多重風險因子介入療法(multiple risk factors intervention therapies, MRFIT)保護腎臟,其中最主要的方法是給予血管張力素轉換酶抑制劑(ACEIs)或血管張力素接受器阻斷劑(ARBs)。因第二型血管張力素(angiotensin Ⅱ)在腎功能的惡化具有重要角色,許多研究已證實ACEIs/ARBs可延遲腎臟疾病的進展。由這兩類藥物的小型、短時間比較試驗,顯示兩者的降血壓和降低蛋白尿效果相當。然而,其藥理機轉和藥效學並不相同,理論上兩者的合併療法或許有加成效果。因目前大多數研究來自非亞洲族群,台灣人使用此兩類藥物的療效尚待探討。本研究評估成大醫院腎臟科門診病患,其血清肌酸酐(serum creatinine, Scr)值大於1.5 mg/dL或每天尿蛋白流失量(daily protein loss, DPL)超過1公克或兩者皆有,且使用ACEIs/ARBs或其他降血壓藥物已達六個月以上,並每年在門診至少追蹤四次,以回溯性方式分析病患的基本資料、疾病、所使用的降血壓藥物,Scr,DPL和血壓變化以及糖化血色素(HbAic)、尿酸、膽固醇和血鉀等。主要的評估指標(腎臟存活率)為Scr或DPL比基礎值增加50%以上,次要的評估指標為患者的血壓控制和血鉀變化。以Kaplan-Meier存活分析與log-rank test分析藥物使用和其他預後因子對腎臟存活率的影響,再以Cox proportional hazard model 校正基礎共變數(baseline covariates)。共有132名慢性腎病患者納入本研究,ACEIs(45位)、ARBs(31位)和合併使用者(3位)為ACEIs/ARBs組(共79位);使用其他降血壓藥物者為對照組(共53位)。兩組的基本性質大致無差異,但對照組的年紀和Scr值較高(66.3±10.5 vs 52.3±15.5歲和2.4±0.9 vs 2.0±1.0 mg/dL; P<0.05)。平均治療28.6和32.5個月後,ACEIs/ARBs的使用與腎臟存活率有相關性;但多變項分析中,只有ACEIs/ARBs的使用有意義。此外,比較ACEIs和ARBs兩組,基本性質方面,ACEIs組的男性較多且血鉀值較高,而其他項目則無差異。平均追蹤31.1和24.6個月後,ARBs組的舒張壓和Scr值均較低(74.3±13 vs 80.1±11.4 mmHg;1.9±0.6 vs 2.4±1.2 mg/dL,P<0.05),但兩組的腎臟存活率和血鉀值,並無差異。本研究證實ACEIs和ARBs對台灣慢性腎病患者的腎臟保護效果與其他文獻報告相類似。另外,在血壓控制及減緩Scr上升方面,ARBs比ACEIs更有效,但ARBs是否確實比ACEIs對腎臟較有助益,仍需作進一步前瞻性研究。 |
英文摘要 | Irrespective of the primary causes, most patients with chronic kidney disease (CKD) eventually progress to end-stage renal disease (ESRD). The epidemiological data shows a rising incidence and prevalence rate of ESRD in Taiwan. To slow renal progression and prevent ESRD, multiple risk factor intervention therapies (MRFIT) can inhibit renal progression. One of the major therapeutic strategies is to inhibit rennin-angiotensin system by angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin Ⅱ type I receptor blockers (ARBs). Both ACEIs and ARBs have similar effects on blood pressure (BP) control and lowering proteinuria. In addition, combination therapy may augment the individual’s benefit. Because most clinical data has been derived from a non-Asian population, we investigated clinical features and therapeutic responses of CKD patients in southern Taiwan. From October 2001 to January 2002, a total of 132 CKD patients, defined as serum creatinine (Scr) > 1.5 mg/dL (n=73), daily urinary protein loss (DPL) > 1g (n=40), or both (n=19), were enrolled in this study. Detailed medical records, including age, gender, smoking, underlying diseases, BP, antihypertensive medications, and blood biochemistry data, were collected. Primary endpoint (i.e. renal survival) was defined as a 50% increase in Scr or DPL from the baseline. Secondaly endpoints included BP control and the change of serum potassium. Kaplan-Meier survival analysis with log-rank test was performed to evaluate the impact of ACEIs/ARBs on renal progression, and the Cox proportional-hazards model was introduced to adjust for confounding variables. These patients were classified into the ACEIs/ARBs group (n=79), treated with ACEIs (n=45), ARBs (n=31) or ACEIs plus ARBs (n-3), and the control group (n=53), treated with other antihypertensive agents. There were no significant differences in the baseline characteristics between the two groups, except an older average age and a higher Scr in the control group. The results showed that the ACEIs/ARBs group had a better renal survival (P=0.047), which was not influenced by BP changes. Univariate analysis of sex, baseline Scr or DPL, and medication showed significant association with renal survival (hazard ratio=3.88, P=0.04). However, medication only, without ACEIs/ARBs, also had an impact on renal survival as determined by multivariate analysis. In comparison with the ARBs group, the ACEIs group was predominantly male and had a higher baseline level of serum potassium. After a mean follow-up of 31.1/24.6 months, diastolic BP and Scr in the ARBs group were significantly lower than in the ACEIs group, but there were no significant differences in renal survival and changes of serum potassium levels between the two groups. In conclusion, our study demonstrated that both ACEIs and ARBs did have renoprotective effects on Taiwanese with CKD. ARBs tended to be more renoprotective than ACEIs, but further prospective study is necessary for confirmation. |
本系統中英文摘要資訊取自各篇刊載內容。