Renin-Angiotensin System Blockade and Long-term Clinical Outcomes in Kidney Transplant Recipients: A Meta-analysis of Randomized Controlled Trials
Renin-Angiotensin System Blockade and Long-term Clinical Outcomes in Kidney Transplant Recipients: A Meta-analysis of Randomized Controlled Trials
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DOI：
10.1053/j.ajkd.2016.08.018
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发表时间：
2017-01-01
影响因子：
13.2
通讯作者：
Knoll, Greg A.
中科院分区：
文献类型：
--
作者：
Hiremath, Swapnil;Fergusson, Dean A.;Knoll, Greg A.
背景：肾素-血管紧张素系统（RAS）阻断已被确立为普通人群治疗的基石，尤其是慢性肾脏疾病。然而，其在肾移植人群中的疗效尚不清楚。研究设计：我们使用MEDLINE（1966年至2015年11月）、Embase（1980年至2015年11月）和Cochrane图书馆（2015年第三季度）进行了系统回顾和荟萃分析，并在PubMed检索了近期未索引的引文。环境与人群：成人肾移植受者。研究选择标准：随机对照试验，随访1年或更长时间，并报告感兴趣的临床结果。干预：RAS阻断剂（血管紧张素转换酶抑制剂或血管紧张素受体阻滞剂）与安慰剂、活性比较剂或标准护理。结果：全因死亡率，全因移植失败，血清肌酐水平翻倍。结果：8项试验（1,502名受试者）被纳入系统评价。与对照组相比，RAS阻断没有显著改变全因死亡率（风险比[RR]， 0.96; 95% CI, 0.62-1.51）、移植失败（RR, 0.76; 95% CI, 0.49-1.18）或肌酐水平翻倍（RR, 0.84; 95% CI, 0.51-1.39）。这一结果在相关亚组（血管紧张素转换酶抑制剂或血管紧张素受体阻滞剂干预，随访>= 1年，基线蛋白尿作为纳入标准）中都是稳健的。RAS阻断组发生高钾血症的风险显著增高（RR, 2.44; 95% CI, 1.53-3.90）。在这些汇总分析中没有统计学上的异质性。局限性：事件数量相对较少（总体而言，8项试验中有71例死亡和72例移植失败），随访时间相对较短（仅有2项试验）。5年)。结论：该分析既不支持也不反驳RAS阻断可改善肾移植受者临床结果的假设。需要一项超过10,000例患者的试验来明确回答RAS阻断是否会减少这一人群的移植损失。与此同时，临床医生应该在个案的基础上对患者使用这些药物的风险和益处进行权衡。(C) 2016年由国家肾脏基金会，Inc。
Background: Renin-angiotensin system [RAS] blockade has been established as the cornerstone of therapy in the general population, and especially in chronic kidney disease. However, its efficacy in the kidney transplant population remains unknown.Study Design: We conducted a systematic review and meta-analysis using MEDLINE (1966 to November 2015), Embase (1980 to November 2015), and the Cochrane Library (third quarter 2015), as well as a PubMed search for recent nonindexed citations.Settings & Population: Adult kidney transplant recipients.Selection Criteria for Studies: Randomized controlled trials, with follow-up of 1 year or longer and reporting clinical outcomes of interest.Intervention: RAS blockade (angiotensin-converting enzyme inhibitors or angiotensin receptor blockers) versus placebo, active comparator, or standard of care.Outcomes: All-cause mortality, all-cause transplant failure, and doubling of serum creatinine level.Results: 8 trials (1,502 participants) were included in the systematic review. RAS blockade did not significantly alter all-cause mortality (risk ratio [RR], 0.96; 95% CI, 0.62-1.51), transplant failure (RR, 0.76; 95% CI, 0.49-1.18), or creatinine level doubling (RR, 0.84; 95% CI, 0.51-1.39) compared to the control group. This result was robust across the subgroups of interest (angiotensin-converting enzyme inhibitor or angiotensin receptor blocker intervention, follow up >= 1 year, and baseline proteinuria as an inclusion criterion). There was significantly higher risk for hyperkalemia with RAS blockade (RR, 2.44; 95% CI, 1.53-3.90). There was no statistical heterogeneity in any of these pooled analyses.Limitations: Relatively smaller number of events (overall, 71 deaths and 72 transplant failures among 8 trials) and relatively short follow-up (only 2 trials. 5 years).Conclusions: This analysis neither supports nor refutes the hypothesis that RAS blockade improves clinical outcomes in kidney transplant recipients. A trial with more than 10,000 patients would be needed to definitively answer whether RAS blockade reduces transplant loss in this population. In the meantime, clinicians should weigh the risks and benefits of using these medications with their patients on a case-by-case basis. (C) 2016 by the National Kidney Foundation, Inc.