Should renin-angiotensin-aldosterone system inhibition enablement be a therapeutic target in CKD patients?
Should renin-angiotensin-aldosterone system inhibition enablement be a therapeutic target in CKD patients?
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肾素-血管紧张素-醛固酮系统抑制是否应该成为 CKD 患者的治疗目标？
DOI：
10.1093/ndt/gfab061
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发表时间：
2021
期刊：
影响因子：
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通讯作者：
Agarwal,Rajiv
中科院分区：
文献类型：
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作者：
Rossignol,Patrick;Agarwal,Rajiv
肾素-血管紧张素-醛固酮系统抑制剂(RAASI)在糖尿病、高血压、心力衰竭和射血分数降低(HFrEF)(后者经常联合应用血管紧张素转换酶抑制剂(ACEIs)/血管紧张素受体阻滞剂(ARB)和盐皮质激素受体拮抗剂(MRAs))和慢性肾脏疾病(CKD)伴蛋白尿的患者中至关重要。循证心脏病学和肾脏学指南强烈建议使用ACEI/ARB[1]；医生坚持指南指导的药物治疗与改善的结果相关。在美国，最近一项针对38885名成人国民健康和营养检查调查参与者的调查显示，尽管ACEI/ARB的使用量在1999年至2014年之间有所增加，但在2003年之后似乎停滞不前，只有大约40%的CKD患者使用ACEI/ARB[2]。值得注意的是，在CKD结果和实践模式研究中，RAASI处方在不同国家之间存在很大差异；与德国(80%)、法国(77%)和巴西(66%)相比，RAASI处方在美国不太常见(52%)[3]。这些差异在慢性肾脏病晚期患者中尤为明显。在这一期的无损检测中，Walther等人[4]在1371075名患有慢性肾脏病的老年美国退伍军人中确定了141252名患者，他们服用了血管紧张素转换酶/血管紧张素转换酶的新处方(17.4%患有充血性心力衰竭)。他们报告说，停用ACEI/ARB与死亡风险增加约2倍，终末期肾病风险增加1.5倍有关。这一分析有力地扩展了迄今为止关于ACEI/ARB停用与慢性肾脏病长期结果的关联的稀少知识，他们的报告中也进行了优雅的回顾。除了观察设计排除了因果关系的确定之外，作者承认的一个限制是无法在该数据库的框架内确定ACEI/ARB停止的确切情况。他们提出的一个正确的理由是，预期寿命脆弱或有限。
Renin–angiotensin–aldosterone system inhibitor (RAASi) use is of paramount importance in patients with diabetes, hypertension, heart failure and reduced ejection fraction (HFrEF)[the latter frequently treated with a combination of angiotensinconverting enzyme inhibitors (ACEIs)/angiotensin receptor blockers (ARBs) and mineralocorticoid receptor antagonists (MRAs)] and chronic kidney disease (CKD) with albuminuria. Their use is strongly recommended by evidence-based cardiology and nephrology guidelines [1]; physician adherence to guideline-directed medical therapy in HFrEF associates with improved outcomes.In the USA, a recent survey among 38885 adult National Health and Nutrition Examination Survey participants with estimated glomerular filtration rate (eGFR)< 60 mL/min/1.73 m2 or urinary albumin-to-creatinine ratio 30mg/g showed that although the use of ACEI/ARB increased between 1999 and 2014, it appeared to plateau after 2003, with approximately only 40% of the CKD population using an ACEI/ARB [2]. Of note, within the CKD Outcomes and Practice Patterns Study, there are substantial variations among countries in RAASi prescription; RAASi prescription was found to be less common (52%) in the USA when compared with Germany (80%), France (77%) and Brazil (66%)[3]. These differences were particularly pronounced in patients with later stages of CKD. In this issue of NDT, Walther et al.[4] in a cohort of 1371075 older US veterans with CKD identified 141252 patients who were given a new prescription of ACEI/ARB (17.4% had congestive heart failure). They reported that ACEI/ARB discontinuation was associated with an approximately 2-fold increased risk of death and 1.5-fold increase in the risk of end-stage kidney disease. This analysis robustly expands the thus far sparse knowledge regarding the association of ACEI/ARB discontinuation with long-term outcomes in CKD, also elegantly reviewed in their report. Aside from the observational design precluding the ascertainment of causality, a limitation acknowledged by the authors, was the inability to determine within the framework of this database the exact circumstances of ACEI/ARB discontinuation. One reason they rightly propose is frailty or limited projected life expectancy.