Huang Rongzhong, Feng Yuxing, Wang Ying, Qin Xiaoxia, Melgiri Narayan Dhruvaraj, Sun Yang, Li Xingsheng
Department of Rehabilitation Medicine, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China.
Department of Neurology, the Ninth People's Hospital of Chongqing, Chongqing, China.
PLoS One. 2017 Jan 3;12(1):e0168582. doi: 10.1371/journal.pone.0168582. eCollection 2017.
Antihypertensive treatment mitigates the progression of chronic kidney disease. Here, we comparatively assessed the effects of antihypertensive agents in normotensive and hypertensive diabetic patients with microalbuminuric kidney disease.
MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were systematically searched for randomized controlled trials (RCTs) comparing oral antihypertensive agents in adult diabetic patients with microalbuminuria. The primary efficacy outcome was reduction in albuminuria, and the primary safety outcomes were dry cough, presyncope, and edema. Random-effects pairwise and Bayesian network meta-analyses were performed to produce outcome estimates for all RCTs, only hypertensive RCTs, or only normotensive RCTs. Surface under the cumulative ranking (SUCRA) probability rankings were calculated for all outcomes. Sensitivity analyses on type 2 diabetes status, age, or follow-up duration were also performed.
A total of 38 RCTs were included in the meta-analyses. The angiotensin-converting enzyme inhibitor-calcium channel blocker (ACEI-CCB) combination therapy of captopril+diltiazem was most efficacious in reducing albuminuria irrespective of blood pressure status. However, the ACEI-angiotensin receptor blocker (ACEI-ARB) combination therapy of trandolapril+candesartan was the most efficacious in reducing albuminuria for normotensive patients, while the ACEI-CCB combination therapy of fosinopril+amlodipine was the most efficacious in reducing albuminuria for hypertensive patients. The foregoing combination therapies displayed inferior safety profiles relative to ACEI monotherapy with respect to dry cough, presyncope, and edema. With respect to type 2 diabetic patients with microalbuminuria, the Chinese herbal medicine Tangshen formula followed by the ACEI ramipril were the most efficacious in reducing albuminuria.
Trandolapril+candesartan appears to be the most efficacious intervention for reducing albuminuria for normotensive patients, while fosinopril+amlodipine appears to be the most efficacious intervention for reducing albuminuria for hypertensive patients. For practitioners opting for monotherapy, our SUCRA analysis supports the use of trandolapril and fosinopril in normotensive and hypertensive adult diabetic patients with microalbuminuria, respectively.
抗高血压治疗可减缓慢性肾病的进展。在此，我们比较评估了抗高血压药物对正常血压和高血压糖尿病微量白蛋白尿肾病患者的影响。
系统检索MEDLINE、EMBASE和Cochrane对照试验中心注册库，以查找比较成年糖尿病微量白蛋白尿患者口服抗高血压药物的随机对照试验（RCT）。主要疗效结局为蛋白尿减少，主要安全性结局为干咳、晕厥前期和水肿。进行随机效应成对和贝叶斯网络荟萃分析，以得出所有RCT、仅高血压RCT或仅正常血压RCT的结局估计值。计算所有结局的累积排序曲线下面积（SUCRA）概率排名。还对2型糖尿病状态、年龄或随访时间进行了敏感性分析。
荟萃分析共纳入38项RCT。卡托普利+地尔硫䓬的血管紧张素转换酶抑制剂-钙通道阻滞剂（ACEI-CCB）联合治疗在降低蛋白尿方面最为有效，无论血压状态如何。然而，群多普利+坎地沙坦的ACEI-血管紧张素受体阻滞剂（ACEI-ARB）联合治疗对正常血压患者降低蛋白尿最为有效，而福辛普利+氨氯地平的ACEI-CCB联合治疗对高血压患者降低蛋白尿最为有效。上述联合治疗在干咳、晕厥前期和水肿方面的安全性不如ACEI单药治疗。对于2型糖尿病微量白蛋白尿患者而言，中药糖肾方其次是ACEI雷米普利在降低蛋白尿方面最为有效。
群多普利+坎地沙坦似乎是降低正常血压患者蛋白尿最有效的干预措施，而福辛普利+氨氯地平似乎是降低高血压患者蛋白尿最有效的干预措施。对于选择单药治疗的医生，我们的SUCRA分析支持分别在正常血压和高血压成年糖尿病微量白蛋白尿患者中使用群多普利和福辛普利。
