College of Medicine, Mayo Health System Practice-Based Research Network, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
Nephron Clin Pract. 2011;118(4):c407-19. doi: 10.1159/000324164. Epub 2011 Mar 7.
Current epidemiological data from the USA, Europe, Asia and the Indian subcontinent, Africa, the Far East, South America, the Middle East and Eastern Europe all point to the increasing incidence of renal failure encompassing acute kidney injury (AKI), chronic kidney disease (CKD) and end-stage renal disease (ESRD). While the explanations for these worldwide epidemics remain speculative, it must be acknowledged that these increases in AKI, CKD and ESRD, happening worldwide, have occurred despite the universal application of strategies of renoprotection over the last 2 decades, more especially the widespread use of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs). We note that many of the published large renin-angiotensin-aldosterone system (RAAS) blockade randomized controlled trials, upon which current evidence-based practice for the increasing use of ACEIs and ARBs for renoprotection derived from, have strong deficiencies that have been highlighted over the years. From reports in the literature, there is an increasing association of exacerbations of renal failure with ACEIs and ARBs, more so in the older hypertensive patient, >65 years old. The biological plausibility for ACEI and ARB to protect the kidneys against a background of potential multiple pathogenetic pathways to account for CKD progression appears to be not very defensible. We reviewed the literature along these lines and submit that ACEIs and ARBs often cause unrecognized significant worsening renal failure in CKD patients, sometimes irreversible, and that more caution is required regarding their use, especially in the older hypertensive patients, with likely ischemic hypertensive nephropathy. Given the increasing association of concomitant RAAS blockade with worsening renal failure following exposure to iodinated contrast, during acute illness, in the perioperative period and following lower bowel preparations prior to colonoscopy, we submit that, preferably, ACEIs and ARBs be withheld for 2-4 days prior to or during these clinical scenarios. This represents the concept of renoprevention.
目前来自美国、欧洲、亚洲和印度次大陆、非洲、远东、南美洲、中东和东欧的流行病学数据都表明，包括急性肾损伤 (AKI)、慢性肾脏病 (CKD) 和终末期肾病 (ESRD) 在内的肾衰竭发病率不断上升。尽管这些全球范围内 AKI、CKD 和 ESRD 发病率增加的原因仍在推测之中，但必须承认，尽管在过去 20 年中普遍应用了肾脏保护策略，特别是广泛使用血管紧张素转换酶抑制剂 (ACEI) 和血管紧张素受体阻滞剂 (ARB)，但这些全球范围内的发病率增加仍然存在。我们注意到，许多已发表的大型肾素-血管紧张素-醛固酮系统 (RAAS) 阻断随机对照试验，其广泛应用 ACEI 和 ARB 来增加肾脏保护的当前循证实践正是源于这些试验，这些试验多年来一直存在严重缺陷。从文献报道来看，ACEI 和 ARB 与肾衰竭加重之间的关联越来越多，在年龄较大的高血压患者 (>65 岁) 中更为明显。从潜在的多种发病机制途径来解释 CKD 进展的角度来看，ACEI 和 ARB 对肾脏的保护作用似乎不太合理。我们沿着这些思路对文献进行了回顾，并认为 ACEI 和 ARB 经常导致 CKD 患者的肾功能恶化，而且往往是不可逆转的，因此在使用这些药物时需要更加谨慎，尤其是在年龄较大的高血压患者中，他们可能患有缺血性高血压性肾病。鉴于 RAAS 阻断剂与碘造影剂接触后、急性疾病期间、围手术期以及结肠镜检查前进行下消化道准备后肾功能恶化的关联不断增加，我们认为，最好在这些临床情况下提前 2-4 天或期间暂停使用 ACEI 和 ARB。这代表了肾脏预防的概念。
