Fresenius Medical Care NA, Waltham, Massachusetts, USA.
Division of Nephrology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
Kidney Int. 2011 Nov;80(9):978-985. doi: 10.1038/ki.2011.228. Epub 2011 Jul 20.
To compare the relative effectiveness of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) in reducing cardiovascular mortality in chronic hemodialysis patients, we conducted an observational analysis of all patients initiated on ACEI or ARB therapy undergoing chronic hemodialysis at a large dialysis provider. Survival curves with mortality hazard ratios (HRs) were generated using the Kaplan-Meier method and Cox regression. Outcomes were compared using inverse probability of treatment weighting and propensity score matching. Over 6 years, 22,800 patients were newly initiated on an ACEI and 5828 on an ARB after at least 60 days of chronic hemodialysis. After adjustment for baseline cardiovascular risk factors, there was no significant difference in the risk of cardiovascular, all-cause, or cerebrovascular mortality in patients initiated on an ARB compared with an ACEI (HR of 0.96). A third of 28,628 patients, newly started on an ACEI or ARB, went on to another antihypertensive medication in succession. After adjustment for risk factors, 701 patients initiated on combined ACEI and ARB therapy (HR of 1.45) or 6866 patients on ACEI and non-ARB antihypertensive agent (HR of 1.27) were at increased risk of cardiovascular death compared with 1758 patients initiated on an ARB and non-ACEI antihypertensive therapy. Thus, an ARB, in combination with another antihypertensive medication (but not an ACEI), may have a beneficial effect on cardiovascular mortality. As observational studies may be confounded by indication, even when adjusted, randomized clinical trials are needed to confirm these findings.
为了比较血管紧张素转换酶抑制剂 (ACEI) 和血管紧张素受体阻滞剂 (ARB) 在降低慢性血液透析患者心血管死亡率方面的相对有效性，我们对在一家大型透析机构接受慢性血液透析且开始使用 ACEI 或 ARB 治疗的所有患者进行了一项观察性分析。使用 Kaplan-Meier 方法和 Cox 回归生成死亡率风险比 (HR) 的生存曲线。使用逆概率治疗加权和倾向评分匹配来比较结果。在 6 年期间，有 22800 名患者在开始慢性血液透析至少 60 天后开始使用 ACEI，5828 名患者开始使用 ARB。在调整了基线心血管危险因素后，与 ACEI 相比，开始使用 ARB 的患者心血管、全因或脑血管死亡率的风险没有显著差异（HR 为 0.96）。在开始使用 ACEI 或 ARB 的 28628 名患者中，有三分之一的患者随后又连续使用了另一种降压药物。在调整了危险因素后，与开始使用 ARB 且未使用 ACEI 降压药物的 1758 名患者相比，开始使用 ACEI 和 ARB 联合治疗（HR 为 1.45）的 701 名患者或开始使用 ACEI 和非 ARB 降压药物（HR 为 1.27）的 6866 名患者心血管死亡的风险增加。因此，与开始使用 ARB 且未使用 ACEI 降压药物的患者相比，ARB 联合另一种降压药物（但不是 ACEI）可能对心血管死亡率有有益影响。由于观察性研究可能受到指示性的影响，即使经过调整，也需要进行随机临床试验来证实这些发现。
