Antiproteinuric response to dual blockade of the renin-angiotensin system in primary glomerulonephritis: Meta-analysis and metaregression
Antiproteinuric response to dual blockade of the renin-angiotensin system in primary glomerulonephritis: Meta-analysis and metaregression
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DOI：
10.1053/j.ajkd.2008.03.008
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发表时间：
2008-09-01
影响因子：
13.2
通讯作者：
Conte, Giuseppe
中科院分区：
文献类型：
--
作者：
Catapano, Fausta;Chiodini, Paolo;Conte, Giuseppe
背景资料：在原发性肾小球肾炎（GN）患者中，血管紧张素转换酶（ACE）抑制剂联合血管紧张素受体阻滞剂（ARB）与单药治疗的抗蛋白尿反应尚不明确，因为研究规模小，反应异质性高。研究设计：荟萃分析/荟萃回归。设置和人群：随机临床试验（RCTs）。研究选择标准：1996年1月至2007年4月发表的RCT。如果无法获得有关蛋白尿水平的信息，患者患有原发性GN以外的肾脏疾病，或患有终末期肾脏疾病，则排除研究。干预：ACE抑制剂加ARB与单药治疗这些药物中的一种。结局：蛋白尿（原发性）、血压、血清钾水平和肾小球滤过率的绝对变化结果：我们发现了13项随机对照试验，包括425例原发性肾小球肾炎患者，蛋白尿范围为0.8至7.9 g/d，年龄为25至60岁。与ACE抑制剂单药治疗相比，联合治疗使蛋白尿减少0.60 g/d（95%置信区间，0.40 - 0.80），与ARB单药治疗相比，联合治疗使蛋白尿减少0.54 g/d（95%置信区间，0.30 - 0.78）。蛋白尿的基线水平解释了联合治疗与单药治疗抗蛋白尿反应的研究间变异性。收缩压和舒张压、GFR、年龄和免疫球蛋白A肾病的诊断并不改变抗蛋白尿反应。ACE抑制剂加ARB治疗不改变GFR，但增加血清钾水平（0.10 mEq/L与ACE抑制剂和0.19 mEq/L与ARB治疗）和降低血压。局限性：仅包括已发表的数据。结论：ACE抑制剂加ARB治疗的抗蛋白尿反应始终高于单药治疗，且与基线蛋白尿严格相关，仅与血清钾水平的中度升高相关，而不是免疫球蛋白A肾病所特有的。
Background: In patients with primary glomerulonephritis (GN), antiproteinuric response to angiotensin-converting enzyme (ACE) inhibitors plus angiotensin receptor blockers (ARBs) versus either monotherapy is undefined because of the small size of studies and high heterogeneity of response.Study Design: Meta-analysis/metaregression.Setting & Population: Randomized clinical trials (RCTs).Selection Criteria for Studies: RCTs published from January 1996 to April 2007. Studies were excluded if information about levels of proteinuria was not available, patients had kidney disease other than primary GN, or if they had end-stage renal disease.Intervention: ACE inhibitor plus ARB versus monotherapy with 1 of these drug classes.Outcomes: Absolute changes in proteinuria (primary), blood pressure, serum potassium level, and glomerular filtration rate (GFR; secondary).Results: We found 13 RCTs including 425 patients with primary GN with proteinuria ranging from 0.8 to 7.9 g/d of protein and age from 25 to 60 years. Combination treatment decreased proteinuria by 0.60 g/d (95% confidence interval, 0.40 to 0.80) versus ACE-inhibitor monotherapy and 0.54 g/d (95% confidence interval, 0.30 to 0.78) versus ARB monotherapy. Baseline levels of proteinuria explained most between-study variability of the antiproteinuric response to combination therapy versus monotherapies. Systolic and diastolic blood pressure, GFR, age, and diagnosis of immunoglobulin A nephropathy did not modify antiproteinuric response. ACE-inhibitor plus ARB therapy did not change GFR, whereas it increased serum potassium levels (by 0.10 mEq/L versus ACE-inhibitor and 0.19 mEq/L versus ARB therapy) and decreased blood pressure.Limitations: Only published data are included.Conclusions: The antiproteinuric response to ACE-inhibitor plus ARB therapy versus either monotherapy is consistently greater and strictly related to baseline proteinuria, associated with only moderate increase in serum potassium levels, and not peculiar to immunoglobulin A nephropathy.