Wei Alice, Burns Godfrey C, Williams Brent A, Mohammed Nazim B, Visintainer Paul, Sivak Steven L
Department of Medicine, Saint Vincent's Hospital and Medical Center, New York, New York 10011, USA.
Kidney Int. 2003 Oct;64(4):1462-71. doi: 10.1046/j.1523-1755.2003.00230.x.
Human immunodeficiency virus (HIV)-associated nephropathy (HIVAN) is the most common cause of end-stage renal disease (ESRD) in HIV-infected patients. Angiotensin-converting enzyme (ACE) inhibition has previously shown a short-term benefit in HIVAN. This study examines the long-term effects of ACE inhibition on renal survival in HIVAN.
In this single-center prospective cohort study, 44 patients with biopsy-proven HIVAN were enrolled prior to the onset of severe renal insufficiency (serum creatinine <or=2.0 mg/dL), throughout the study period of 1890 days (5.1 years). Twenty-eight patients received fosinopril, 10 mg/day, and 16 were followed as controls. End points included ESRD and death. Treatment effects on survival were evaluated with Kaplan-Meier product-limit estimates. Survival is also described as absolute median number of days.
Median renal survival of treated patients was 479.5 days, with only one patient developing ESRD. All untreated controls progressed to ESRD, with a median renal survival of 146.5 days (P < 0.0001). There were no significant differences between treatment and control groups in age, significant exposure to antiretroviral therapy, defined as >or=two antiviral drugs for >or=30 consecutive days, CD4 lymphocyte count, initial median serum creatinine concentration, or proteinuria. Risk of renal failure was reduced with ACE inhibitors (RR = 0.003, P < 0.0001). Exposure to antiretroviral therapy did not have a significant impact on the risk of renal failure. Of the ACE inhibitor-treated group, 87.5% survived compared with 21.4% of the control group (P < 0.001).
ACE inhibition initiated prior to severe renal insufficiency may offer long-term renal survival benefits in HIVAN. Diagnosis should be sought early in patients with clinical signs suggestive of HIVAN.
人类免疫缺陷病毒（HIV）相关性肾病（HIVAN）是HIV感染患者终末期肾病（ESRD）的最常见病因。血管紧张素转换酶（ACE）抑制治疗此前已显示对HIVAN有短期益处。本研究探讨ACE抑制治疗对HIVAN患者肾脏存活的长期影响。
在这项单中心前瞻性队列研究中，44例经活检证实为HIVAN的患者在严重肾功能不全（血清肌酐≤2.0mg/dL）发作前入组，研究期为1890天（5.1年）。28例患者接受福辛普利治疗，每日10mg，16例作为对照进行随访。终点包括ESRD和死亡。用Kaplan-Meier乘积限估计法评估治疗对生存的影响。生存情况也用绝对中位天数描述。
治疗组患者的中位肾脏存活时间为479.5天，仅有1例患者发展为ESRD。所有未治疗的对照组均进展为ESRD，中位肾脏存活时间为146.5天（P<0.0001）。治疗组和对照组在年龄、接受抗逆转录病毒治疗（定义为连续≥30天使用≥2种抗病毒药物）、CD4淋巴细胞计数、初始中位血清肌酐浓度或蛋白尿方面无显著差异。ACE抑制剂可降低肾衰竭风险（RR=0.003，P<0.0001）。接受抗逆转录病毒治疗对肾衰竭风险无显著影响。ACE抑制剂治疗组的生存率为87.5%，而对照组为21.4%（P<0.001）。
在严重肾功能不全之前开始的ACE抑制治疗可能对HIVAN患者的肾脏长期存活有益。对于有HIVAN临床体征的患者应尽早进行诊断。
