Racial differences in the renal response to blood pressure lowering during chronic angiotensin-converting enzyme inhibition: a prospective double-blind randomized comparison of fosinopril and lisinopril in older hypertensive patients with chronic renal in
Racial differences in the renal response to blood pressure lowering during chronic angiotensin-converting enzyme inhibition: a prospective double-blind randomized comparison of fosinopril and lisinopril in older hypertensive patients with chronic renal in
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慢性血管紧张素转换酶抑制期间肾脏对血压降低反应的种族差异：福辛普利和赖诺普利在患有慢性肾病的老年高血压患者中的前瞻性双盲随机比较
DOI：
10.1016/s0272-6386(97)90464-9
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发表时间：
1997
期刊：
影响因子：
--
通讯作者：
Toto,RD
中科院分区：
文献类型：
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作者：
Mitchell,HC;Smith,RD;Cutler,RE;Sica,D;Videen,J;Thompsen-Bell,S;Jones,K;Bradley-Guidry,C;Toto,RD
本研究旨在比较慢性血管紧张素转换酶（ACE）抑制剂对老年黑人和非黑人高血压伴慢性肾功能不全患者血压（BP）和肾血流动力学的影响。进行了一项多中心、安慰剂导入、双盲、平行组研究，以比较ACE抑制剂福辛普利（n = 14）和赖诺普利（n = 13）每日一次治疗22周的降压疗效和肾脏血流动力学反应。研究目标是将舒张压（DBP）降至90 mm Hg或更低，6周后如果血压未达到目标，则加用呋塞米。在大学医学中心的门诊，研究了27例老年高血压患者（≥ 45岁; 12例黑人，15例非黑人; 19例男性，8例女性），DBP ≥ 95 mm Hg，4小时肌酐清除率20 - 70 mL/min/1.73 m2。测量BP、肾小球滤过率（GFR）和肾血浆流量（RPF）较基线的变化（Δ）。平均收缩压（SBP）和DBP显著降低，随机组的降低程度相似：福辛普利（平均值± SEM）第6周时的ΔDBP为−13 ± 2（P < 0.0001; 95%CI，-16至-9），22周时为-12 ± 2（P < 0.0001; 95%CI，−16至−9）;赖诺普利ΔBP在6周时为−14 ± 6（P < 0.0001; 95%CI，−10至−18），在22周时为−16 ± 2（P < 0.0001; 95%CI，−12至−21）。两组GFR和RPF均无显著变化。黑人和非黑人的血压显著降低，程度相似：黑人6周时的ΔDBP为-11 ± 3（P < 0.05; 95% CI，-0.01至-9），22周时为-16 ± 2（P < 0.0001; 95%CI，−11至−20）;对于非黑人，6周时的ΔDBP为−14 ± 1（P < 0.0001; 95%CI，−12至−17），22周时为−12 ± 2（P < 0.0001; 95%CI，−16至−8）。8名患者（5名黑人和3名非黑人）需要在6周后添加呋塞米，以达到22周时DBP < 90 mmHg的目标。在6周时，两个种族组的GFR均未发生显著变化;然而，在22周时，黑人的GFR显著降低（Δ GFR，−16 ± 5; P < 0.006; 95% CI，−26至−5），而非黑人的GFR有增加的趋势（Δ GFR，7 ± 6; P > 0.25）。ΔGFR与ΔRPF直接相关（ΔGFR = 0.0811 <$ΔRPF −2.35 +; r = 0.66; P < 0.003）。在黑人和非黑人中，ΔMAP与ΔGFR或ΔRPF之间没有相关性。我们得出结论，福辛普利和赖诺普利单独或联合呋塞米慢性ACE抑制降低血压的老年黑人和非黑人高血压和慢性肾功能不全。肾血流动力学对慢性ACE抑制的反应存在种族差异，似乎与利尿剂的使用和血压降低的幅度无关。
This study was undertaken to compare the effects of chronic angiotensin-converting enzyme (ACE) inhibition on blood pressure (BP) and renal hemodynamics in older black and nonblack hypertensive patients with chronic renal insufficiency. A multicenter, placebo lead-in double-blind, parallel group study was performed to compare the antihypertensive efficacy and renal hemodynamic response to the once-daily ACE inhibitors fosinopril (n = 14) and lisinopril (n = 13) over a 22-week period. The study goal was to lower diastolic blood pressure (DBP) to 90 mm Hg or less. Furosemide was added after 6 weeks if blood pressure goal was not achieved. At outpatient clinics at university medical centers, 27 older hypertensive patients (≥ 45 years; 12 blacks, 15 nonblacks; 19 male, eight female) with DBP of 95 mm Hg or higher and 4-hour creatinine clearance 20 to 70 mL/min/1.73 m2were studied. Changes (Δ) from baseline in BP, glomerular filtration rate (GFR), and renal plasma flow (RPF) were measured. Mean systolic blood pressure (SBP) and DBP decreased significantly and to a similar extent in randomized groups: fosinopril (mean ± SEM) ΔDBP at 6 weeks was −13 ± 2 (P < 0.0001; 95% Cl, −16 to −9) and at 22 weeks was −12 ± 2 (P < 0.0001; 95% CI, −16 to −9); lisinopril ΔBP at 6 weeks was −14 ± 6 (P < 0.0001; 95% CI, −10 to −18) and at 22 weeks was −16 ± 2 (P < 0.0001; 95% CI, −12 to −21). GFR and RPF did not change significantly in either group. BP was significantly reduced and to a similar extent in blacks and nonblacks: for blacks, ΔDBP at 6 weeks was −11 ± 3 (P < 0.05; 95% CI, −0.01 to −9) and at 22 weeks was −16 ± 2 (P < 0.0001; 95% CI, −11 to −20); for nonblacks, ΔDBP at 6 weeks was −14 ± 1 (P < 0.0001; 95% CI, −12 to −17) and at 22 weeks was −12 ± 2 (P < 0.0001; 95% CI, −16 to −8). Eight patients (five blacks and three nonblacks) required an addition of furosemide after 6 weeks to reach the DBP goal of < 90 mm Hg at 22 weeks. GFR was not significantly altered for either racial group at 6 weeks; however, at 22 weeks, GFR decreased significantly in blacks (Δ GFR, −16 ± 5; P < 0.006; 95% Cl, −26 to −5) and tended to increase in nonblacks (Δ GFR, 7 ± 6; P > 0.25). ΔGFR correlated directly with the ΔRPF (ΔGFR = 0.0811∗ΔRPF −2.35 +; r = 0.66; P < 0.003). There was no correlation between ΔMAP and ΔGFR or ΔRPF in blacks or nonblacks. We conclude that chronic ACE inhibition with fosinopril and lisinopril alone or in combination with furosemide lowers BP in older blacks and nonblacks with hypertension and chronic renal insufficiency. Racial differences in the renal hemodynamic response to chronic ACE inhibition were noted and appear to be independent of diuretic use and the magnitude of BP lowering.