Wang Amanda Y, Bellomo Rinaldo, Ninomiya Toshiharu, Lo Serigne, Cass Alan, Jardine Meg, Gallagher Martin
Renal and Metabolic Division, The George Institute for Global Health, Sydney, New South Wales, Australia; Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia.
Nephrology (Carlton). 2014 Oct;19(10):617-22. doi: 10.1111/nep.12284.
Acute kidney injury (AKI) is associated with increased mortality. While angiotensin-converting enzyme inhibitors (ACEI) are known to slow progression of chronic kidney disease, their role in AKI remains unclear.
The Randomised Evaluation of Normal vs. Augmented Level Replacement Therapy (RENAL) study data were analysed according to ACEI use over time. The primary outcome was all-cause mortality at 90 days following randomisation. Analyses used a multivariate Cox model adjusted for either baseline or for time-dependent covariates, and a sensitivity analysis of patients surviving to at least the median time to ACEI initiation.
Of the 1463 participants with available data on ACE inhibitors usage, 142 (9.7%) received ACEI at least once during study data collection. Participants treated with ACEI were older (P = 0.02) and had less sepsis at baseline (P < 0.001). ACEI use was significantly associated with lower mortality at 90 days (HR 0.46, 95% CI 0.30-0.71, P < 0.001), and an increase in renal replacement therapy-free days (P < 0.001), intensive care unit-free days (P < 0.001) and hospital free-days (P < 0.001) after adjusting for baseline covariates. Using the time-dependent analysis, however, the effect of ACEI administration was not significant (HR 0.78, 95% CI 0.51-1.21, P = 0.3). The sensitivity analysis in day 8 survivors produced similar results.
In the RENAL study cohort, the use of ACEI during the study was not common and, after adjustment for time-dependent covariates, was not significantly associated with reductions in mortality. Further assessment of the effect of ACEI use in AKI patients is needed.
急性肾损伤（AKI）与死亡率增加相关。虽然已知血管紧张素转换酶抑制剂（ACEI）可减缓慢性肾脏病的进展，但其在AKI中的作用仍不明确。
根据随时间使用ACEI的情况对正常与强化水平替代治疗随机评估（RENAL）研究数据进行分析。主要结局是随机分组后90天的全因死亡率。分析采用多变量Cox模型，对基线或时间依赖性协变量进行了校正，并对至少存活至ACEI开始使用的中位时间的患者进行了敏感性分析。
在1463名有ACE抑制剂使用可用数据的参与者中，142名（9.7%）在研究数据收集期间至少接受过一次ACEI治疗。接受ACEI治疗的参与者年龄较大（P = 0.02），且基线时脓毒症较少（P < 0.001）。使用ACEI与90天时较低的死亡率显著相关（风险比0.46，95%置信区间0.30 - 0.71，P < 0.001），并且在调整基线协变量后，无肾脏替代治疗天数增加（P < 0.001）、无重症监护病房天数增加（P < 0.001）以及无住院天数增加（P < 0.001）。然而，采用时间依赖性分析时，ACEI给药的效果不显著（风险比0.78，95%置信区间0.51 - 1.21，P = 0.3）。对第8天存活者的敏感性分析产生了类似结果。
在RENAL研究队列中，研究期间ACEI的使用并不常见，并且在调整时间依赖性协变量后，与死亡率降低无显著关联。需要进一步评估ACEI在AKI患者中的使用效果。
