Division of Nephrology and Hypertension, Case Western Reserve University, University Hospitals Case Medical Center, USA.
Clin J Am Soc Nephrol. 2012 Jun;7(6):989-1002. doi: 10.2215/CJN.07800811. Epub 2012 Apr 5.
CKD is common among older patients. This article assesses long-term renal and cardiovascular outcomes in older high-risk hypertensive patients, stratified by baseline estimated GFR (eGFR), and long-term outcome efficacy of 5-year first-step treatment with amlodipine or lisinopril, each compared with chlorthalidone.
DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: This was a long-term post-trial follow-up of hypertensive participants (n=31,350), aged ≥55 years, randomized to receive chlorthalidone, amlodipine, or lisinopril for 4-8 years at 593 centers. Participants were stratified by baseline eGFR (ml/min per 1.73 m(2)) as follows: normal/increased (≥90; n=8027), mild reduction (60-89; n=17,778), and moderate/severe reduction (<60; n=5545). Outcomes were cardiovascular mortality (primary outcome), total mortality, coronary heart disease, cardiovascular disease, stroke, heart failure, and ESRD.
After an average 8.8-year follow-up, total mortality was significantly higher in participants with moderate/severe eGFR reduction compared with those with normal and mildly reduced eGFR (P<0.001). In participants with an eGFR <60, there was no significant difference in cardiovascular mortality between chlorthalidone and amlodipine (P=0.64), or chlorthalidone and lisinopril (P=0.56). Likewise, no significant differences were observed for total mortality, coronary heart disease, cardiovascular disease, stroke, or ESRD.
CKD is associated with significantly higher long-term risk of cardiovascular events and mortality in older hypertensive patients. By eGFR stratum, 5-year treatment with amlodipine or lisinopril was not superior to chlorthalidone in preventing cardiovascular events, mortality, or ESRD during 9-year follow-up. Because data on proteinuria were not available, these findings may not be extrapolated to proteinuric CKD.
CKD 在老年患者中很常见。本文评估了基线估计肾小球滤过率（eGFR）分层的老年高危高血压患者的长期肾脏和心血管结局，并评估了氨氯地平或赖诺普利与氯噻酮相比，5 年起始治疗的长期疗效。
设计、地点、参与者和测量：这是一项对高血压参与者（n=31350，年龄≥55 岁）的长期临床试验随访，这些参与者随机接受氯噻酮、氨氯地平或赖诺普利治疗 4-8 年，在 593 个中心进行。根据基线 eGFR（ml/min/1.73m2）将参与者分层如下：正常/增加（≥90；n=8027）、轻度降低（60-89；n=17778）和中度/重度降低（<60；n=5545）。结局为心血管死亡率（主要结局）、总死亡率、冠心病、心血管疾病、卒中和心力衰竭以及终末期肾病。
平均 8.8 年的随访后，eGFR 中度/重度降低的参与者总死亡率明显高于 eGFR 正常和轻度降低的参与者（P<0.001）。在 eGFR<60 的参与者中，氯噻酮与氨氯地平（P=0.64）或氯噻酮与赖诺普利（P=0.56）之间心血管死亡率无显著差异。同样，总死亡率、冠心病、心血管疾病、卒中和终末期肾病也无显著差异。
CKD 与老年高血压患者长期发生心血管事件和死亡的风险显著增加相关。根据 eGFR 分层，5 年氨氯地平或赖诺普利治疗与氯噻酮相比，在 9 年随访期间不能预防心血管事件、死亡率或终末期肾病。由于蛋白尿数据不可用，这些发现可能不适用于蛋白尿性 CKD。
