Differential effects of calcium antagonist subclasses on markers of nephropathy progression
Differential effects of calcium antagonist subclasses on markers of nephropathy progression
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DOI：
10.1111/j.1523-1755.2004.00620.x
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发表时间：
2004-06-01
影响因子：
19.6
通讯作者：
Weis-McNulty, A
中科院分区：
文献类型：
--
作者：
Bakris, GL;Weir, MR;Weis-McNulty, A
背景资料。大量研究表明，二氢吡啶类钙拮抗剂(DCA)和非二氢吡啶类钙拮抗剂(NDCA)具有不同的抗蛋白尿作用。蛋白尿减少与肾脏疾病的进展相关。在早期的系统综述中，钙拮抗剂被证明是有效的降压药物，但对于有蛋白尿和肾功能不全的患者，其肾脏益处尚不确定。我们进行了一项系统的综述，以评估DCA和NDCA对合并或不合并糖尿病的高血压成人蛋白尿的不同影响，并确定这些不同的影响是否转化为肾病进展的改变。纳入综述的研究必须是随机临床试验，治疗至少6个月，包括DCA或NDCA治疗组，有一个或多个肾脏终点，并在1986年后启动。摘要数据是从28项研究中提取的，这些研究被输入两个相同但独立的数据库，由独立的评价者比较和评估。观察每类药物对血压(N=1338)和蛋白尿(N=510)的影响。在调整样本量、研究长度和基线值后，两类钙拮抗剂的降压能力在统计学上没有显著差异。DCA组和NDCA组尿蛋白平均变化分别为+2%和-30%(95%CI，10%~54%，P=0.01)。尽管在血压降低或糖尿病的存在方面没有显著差异，但使用NDCA与使用DCA相比，蛋白尿的下降幅度一直更大。这一分析支持(1)钙拮抗剂亚类之间在降低血压方面的相似疗效，以及(2)在存在或不存在糖尿病的情况下，NDCA比DCA更能减少蛋白尿。基于这些发现，NDCA单独或与血管紧张素转换酶(ACE)抑制剂或血管紧张素受体阻滞剂(ARB)联合使用，被认为是高血压肾病合并蛋白尿患者降压的首选药物。
Background. Numerous studies suggest that the dihydropyridine calcium antagonists (DCAs) and nondihydropyridine calcium antagonists (NDCAs) have differential antiproteinuric effects. Proteinuria reduction is a correlate of the progression of renal disease. In an earlier systematic review, calcium antagonists were shown as effective antihypertensive drugs, but there was uncertainty about their renal benefits in patients with proteinuria and renal insufficiency.Methods. A systematic review was conducted to assess the differential effects of DCAs and NDCAs on proteinuria in hypertensive adults with proteinuria, with or without diabetes, and to determine whether these differential effects translate into altered progression of nephropathy. Studies included in the review had to be randomized clinical trials with at least 6 months of treatment, include a DCA or NDCA treatment arm, have one or more renal end points, and have been initiated after 1986. Summary data were extracted from 28 studies entered into two identical but separate databases, which were compared and evaluated by independent reviewers. The effects of each drug class on blood pressure (N=1338) and proteinuria (N=510) were assessed.Results. After adjusting for sample size, study length, and baseline value, there were no statistically significant differences in the ability of either class of calcium antagonist to decrease blood pressure. The mean change in proteinuria was +2% for DCAs and -30% for NDCAs (95% CI, 10% to 54%, P=0.01). Consistently greater reductions in proteinuria were associated with the use of NDCAs compared with DCAs, despite no significant differences in blood pressure reduction or presence of diabetes.Conclusion. This analysis supports (1) similar efficacy between subclasses of calcium antagonists to lower blood pressure, and (2) greater reductions in proteinuria by NDCAs compared to DCAs in the presence or absence of diabetes. Based on these findings, NDCAs, alone or in combination with an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin receptor blocker (ARB), are suggested as preferred agents to lower blood pressure in hypertensive patients with nephropathy associated with proteinuria.