Yang Chung-Wei, Tzeng Nian-Sheng, Yin Yun-Ju, Li Chien-Hsun, Chen Hung-An, Chiu Shih-Hsiang, Ho Shinn-Ying, Huang Hui-Ling
Division of Nephrology, Department of Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsin-chu, Taiwan; Department of Biological Science and Technology, National Chiao Tung University, Hsinchu, Taiwan.
Department of Psychiatry, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, Taipei, Taiwan; Student Counseling Center, National Defense Medical Center, Taipei, Taiwan.
PLoS One. 2015 Oct 21;10(10):e0140633. doi: 10.1371/journal.pone.0140633. eCollection 2015.
Major adverse cardiovascular events (MACE) cause the leading cause of morbidity and mortality in patients with end-stage renal disease (ESRD) on maintenance Hemodialysis (HD) or peritoneal dialysis (PD). Many randomized-controlled trials (RCTs) have proved that angiotensin receptor blockers (ARBs) can reduce the risk of MACE in the people with normal or impaired kidney function without dialysis. This study seeks to clarify whether ARBs therapy could also attenuate this risk in patients with ESRD on maintenance dialysis.
The National Health Research Institute provided a database of one million random subjects for the study. A random sample was taken of 1800 patients ≥18 years y/o with ESRD on dialysis without a history of MACE and use of ARBs within 6-months prior to enrollment. Cox proportional hazard regression analysis was used to identify the risk factors and compute the hazard ratios accompanying 95% confidence intervals.
In these 1800 patients, 1061 had never used ARBs, while 224 had used them for 1-90 days, and 515 had used them for more than 90 days. We found that ARBs significantly decrease the incidences of acute myocardial infarctions (AMI), coronary artery diseases (CAD) requiring coronary stent or percutaneous transluminal coronary angioplasty (PTCA), peripheral artery disease (PAD) requiring percutaneous transluminal angioplasty (PTA), and acute stroke. Cumulative prescription days of ARBs beyond 365-760 days or more were found to be negatively correlated with incidence of MACEs. For patients with dual comorbidity (i.e., mellitus and hyperlipidemia), 91-365 cumulative prescription days might also attenuate the risk.
For patients on maintenance dialysis, the use of ARBs could significantly attenuate the risk of major cardiovascular events: AMI, acute stroke, and PAD requiring PTA.
主要不良心血管事件（MACE）是维持性血液透析（HD）或腹膜透析（PD）的终末期肾病（ESRD）患者发病和死亡的主要原因。许多随机对照试验（RCT）已证明，血管紧张素受体阻滞剂（ARB）可降低肾功能正常或受损且未接受透析治疗人群发生MACE的风险。本研究旨在阐明ARB治疗是否也能降低维持性透析的ESRD患者发生这种风险的可能性。
国家卫生研究院提供了一个包含100万随机受试者的数据库用于本研究。对1800例年龄≥18岁、正在接受透析且无MACE病史且在入组前6个月内未使用过ARB的ESRD患者进行随机抽样。采用Cox比例风险回归分析来识别风险因素并计算伴有95%置信区间的风险比。
在这1800例患者中，1061例从未使用过ARB，224例使用过1 - 90天，515例使用过超过90天。我们发现，ARB可显著降低急性心肌梗死（AMI）、需要冠状动脉支架或经皮冠状动脉腔内血管成形术（PTCA）的冠状动脉疾病（CAD）、需要经皮腔内血管成形术（PTA）的外周动脉疾病（PAD）以及急性卒中的发生率。发现ARB累计处方天数超过365 - 760天或更长时间与MACE发生率呈负相关。对于患有双重合并症（即糖尿病和高脂血症）的患者，91 - 365天的累计处方天数也可能降低风险。
对于维持性透析患者，使用ARB可显著降低主要心血管事件的风险：AMI、急性卒中和需要PTA的PAD。
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