Mavrakanas Thomas A, Gariani Karim, Martin Pierre-Yves
General Internal Medicine Division, Geneva University Hospitals, Geneva, Switzerland.
General Internal Medicine Division, Geneva University Hospitals, Geneva, Switzerland.
Eur J Intern Med. 2014 Feb;25(2):173-6. doi: 10.1016/j.ejim.2013.11.007. Epub 2013 Dec 4.
Blockade of the renin-angiotensin-aldosterone system (RAAS) is a standard therapeutic intervention in diabetic patients with chronic kidney disease (CKD). Concomitant mineralocorticoid receptor blockade has been studied as a novel approach to further slow down CKD progression. We used PubMed and EMBASE databases to search for relevant literature. We included in our review eight studies in patients of at least 18 years of age, with a diagnosis of type 1 or type 2 diabetes mellitus and diabetic nephropathy, under an angiotensin converting enzyme inhibitor (ACEI) and/or an angiotensin II receptor blocker (ARB) as standard treatment. A subset of patients in each study also received a mineralocorticoid receptor blocker (MRB) (either spironolactone or eplerenone) in addition to standard treatment. Combined treatment with a mineralocorticoid receptor blocker further reduced albuminuria by 23 to 61% compared with standard treatment. Estimated glomerular filtration rate values upon study completion slightly decreased under combined treatment. Blood pressure levels upon study completion were significantly lower with combined treatment in three studies. Hyperkalemia prevalence increased in patients under combined treatment raising dropout rate up to 17%. Therefore, combined treatment by an ACEI/ARB and a MRB may further decrease albuminuria in diabetic nephropathy. This effect may be due to the specific properties of the MRB treatment. Clinicians should regularly check potassium levels because of the increased risk of hyperkalemia. Available evidence should be confirmed by an adequately powered comparative trial of the standard treatment (ACEI or ARB) versus combined treatment by an ACEI/ARB and a MRB.
阻断肾素 - 血管紧张素 - 醛固酮系统（RAAS）是糖尿病合并慢性肾脏病（CKD）患者的标准治疗干预措施。联用盐皮质激素受体阻断剂作为一种减缓CKD进展的新方法已得到研究。我们使用PubMed和EMBASE数据库检索相关文献。我们纳入了八项研究，研究对象为年龄至少18岁、诊断为1型或2型糖尿病及糖尿病肾病、接受血管紧张素转换酶抑制剂（ACEI）和/或血管紧张素II受体阻滞剂（ARB）作为标准治疗的患者。每项研究中的一部分患者除标准治疗外还接受了盐皮质激素受体阻断剂（MRB）（螺内酯或依普利酮）治疗。与标准治疗相比，联用盐皮质激素受体阻断剂可使蛋白尿进一步降低23%至61%。研究结束时，联合治疗组的估计肾小球滤过率值略有下降。三项研究显示，联合治疗组研究结束时的血压水平显著降低。联合治疗组患者高钾血症患病率增加，导致脱落率高达17%。因此，ACEI/ARB与MRB联合治疗可能会进一步降低糖尿病肾病患者的蛋白尿。这种效果可能归因于MRB治疗的特殊性质。由于高钾血症风险增加，临床医生应定期检查血钾水平。现有证据应由一项关于标准治疗（ACEI或ARB）与ACEI/ARB联合MRB治疗的充分有力的对比试验予以证实。
