Cravedi Paolo, Remuzzi Giuseppe, Ruggenenti Piero
Department of Medicine and Transplantation, Mario Negri Institute for Pharmacological Research - Azienda Ospedaliera, Ospedali Riuniti di Bergamo, Bergamo, Italy.
Semin Dial. 2011 May-Jun;24(3):290-7. doi: 10.1111/j.1525-139X.2011.00939.x.
Patients on chronic dialysis therapy have a dramatic excess cardiovascular risk compared to any other population, including those with overt diabetic nephropathy. Despite this, patients on dialysis are almost invariably excluded from trials evaluating the cardioprotective effect of novel treatments. Consistent evidence is available that inhibitors of the renin-angiotensin system, such as angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs), are more cardioprotective than other antihypertensive agents in patients with chronic renal disease or diabetes (with or without renal involvement), but whether this applies also to patients on dialysis is unknown. However, clear evidence is available that ACE inhibitors and ARBs reduce morbidity and mortality in patients on dialysis with heart failure (HF) or atrial fibrillation (AF). Moreover, these drugs may preserve residual renal function in those with preterminal kidney failure as well as vascular access and peritoneal membrane function in those on extracorporeal or peritoneal dialysis, respectively. These drugs also show an excellent tolerability profile in this population. Thus, ACE inhibitors and ARBs are indicated in patients on dialysis with HF or AF. Available evidence suggests that they should be first-choice therapy in patients on dialysis with hypertension, though trials are still needed to formally demonstrate their superior cardioprotective effect over other antihypertensives in this population.
与任何其他人群相比，接受慢性透析治疗的患者心血管风险显著更高，包括那些患有显性糖尿病肾病的患者。尽管如此，透析患者几乎总是被排除在评估新型治疗方法心脏保护作用的试验之外。有一致的证据表明，肾素-血管紧张素系统抑制剂，如血管紧张素转换酶（ACE）抑制剂或血管紧张素II受体阻滞剂（ARB），在慢性肾病或糖尿病患者（无论有无肾脏受累）中比其他抗高血压药物更具心脏保护作用，但这是否也适用于透析患者尚不清楚。然而，有明确的证据表明，ACE抑制剂和ARB可降低透析合并心力衰竭（HF）或心房颤动（AF）患者的发病率和死亡率。此外，这些药物可能分别保留终末期肾衰竭患者的残余肾功能以及体外或腹膜透析患者的血管通路和腹膜功能。这些药物在该人群中也表现出良好的耐受性。因此，ACE抑制剂和ARB适用于透析合并HF或AF的患者。现有证据表明，它们应该是透析合并高血压患者的首选治疗方法，尽管仍需要试验来正式证明它们在该人群中比其他抗高血压药物具有更好的心脏保护作用。
