The George Institute for Global Health, The University of Sydney, Sydney, Australia.
CMAJ. 2013 Aug 6;185(11):949-57. doi: 10.1503/cmaj.121468. Epub 2013 Jun 24.
Recent guidelines suggest lowering the target blood pressure for patients with chronic kidney disease, although the strength of evidence for this suggestion has been uncertain. We sought to assess the renal and cardiovascular effects of intensive blood pressure lowering in people with chronic kidney disease.
We performed a systematic review and meta-analysis of all relevant reports published between 1950 and July 2011 identified in a search of MEDLINE, Embase and the Cochrane Library. We included randomized trials that assigned patients with chronic kidney disease to different target blood pressure levels and reported kidney failure or cardiovascular events. Two reviewers independently identified relevant articles and extracted data.
We identified 11 trials providing information on 9287 patients with chronic kidney disease and 1264 kidney failure events (defined as either a composite of doubling of serum creatinine level and 50% decline in glomerular filtration rate, or end-stage kidney disease). Compared with standard regimens, a more intensive blood pressure-lowering strategy reduced the risk of the composite outcome (hazard ratio [HR] 0.82, 95% confidence interval [CI] 0.68-0.98) and end-stage kidney disease (HR 0.79, 95% CI 0.67-0.93). Subgroup analysis showed effect modification by baseline proteinuria (p = 0.006) and markers of trial quality. Intensive blood pressure lowering reduced the risk of kidney failure (HR 0.73, 95% CI 0.62-0.86), but not in patients without proteinuria at baseline (HR 1.12, 95% CI 0.67-1.87). There was no clear effect on the risk of cardiovascular events or death.
Intensive blood pressure lowering appears to provide protection against kidney failure events in patients with chronic kidney disease, particularly among those with proteinuria. More data are required to determine the effects of such a strategy among patients without proteinuria.
最近的指南建议降低慢性肾脏病患者的目标血压，尽管这一建议的证据强度尚不确定。我们旨在评估强化降压对慢性肾脏病患者的肾脏和心血管影响。
我们对 1950 年至 2011 年 7 月间 MEDLINE、Embase 和 Cochrane 图书馆检索到的所有相关报告进行了系统评价和荟萃分析。我们纳入了将慢性肾脏病患者分配到不同目标血压水平并报告肾衰竭或心血管事件的随机试验。两位评审员独立识别相关文章并提取数据。
我们确定了 11 项试验，提供了 9287 例慢性肾脏病患者和 1264 例肾衰竭事件（定义为血清肌酐水平翻倍和肾小球滤过率下降 50%的复合，或终末期肾病）的信息。与标准方案相比，更强化的降压策略降低了复合结局（风险比[HR]0.82，95%置信区间[CI]0.68-0.98）和终末期肾病（HR 0.79，95%CI 0.67-0.93）的风险。亚组分析显示，基线蛋白尿（p=0.006）和试验质量标志物存在效应修饰。强化降压降低了肾衰竭的风险（HR 0.73，95%CI 0.62-0.86），但在基线无蛋白尿的患者中无此效果（HR 1.12，95%CI 0.67-1.87）。对心血管事件或死亡的风险无明显影响。
强化降压似乎可提供对慢性肾脏病患者肾衰竭事件的保护，尤其是蛋白尿患者。需要更多数据来确定无蛋白尿患者中这种策略的效果。
