University of Groningen, University Medical Centre Groningen, Department of Clinical Pharmacy and Pharmacology, Groningen, The Netherlands.
Diabetes Obes Metab. 2018 Jun;20(6):1377-1383. doi: 10.1111/dom.13226. Epub 2018 Feb 20.
To assess variability in systolic blood pressure (SBP) and albuminuria (urinary albumin creatinine ratio [UACR]) responses in patients with type 2 diabetes mellitus initiating renin angiotensin aldosterone system (RAAS) inhibition, and to assess the association of response variability with cardiovascular outcomes.
We performed an observational cohort study in patients with type 2 diabetes who started RAAS inhibition between 2007 and 2013 (n = 1600). Patients were identified from general practices in the Netherlands. Individual response in SBP and UACR was assessed during 15 months' follow-up. Patients were categorized as: good responders (∆SBP <0 mm Hg and ∆UACR <0%); intermediate responders (∆SBP <0 mm Hg and ∆UACR >0% or ∆SBP >0 mm Hg and ∆UACR <0%); or poor responders (∆SBP >0 mm Hg and ∆UACR >0%). Multivariable Cox regression was performed to test the association between initial RAAS inhibition response and subsequent cardiovascular outcomes.
After starting RAAS inhibition, the mean SBP change was -13.2 mm Hg and the median UACR was -36.6%, with large between-individual variability, both in SBP [5th to 95th percentile: 48.5-20] and UACR [5th to 95th percentile: -87.6 to 171.4]. In all, 812 patients (51%) were good responders, 353 (22%) had a good SBP but poor UACR response, 268 (17%) had a good UACR but poor SBP response, and 167 patients (10%) were poor responders. Good responders had a lower risk of cardiovascular events than poor responders (hazard ratio 0.51, 95% confidence interval 0.30-0.86; P = .012).
SBP and UACR response after RAAS inhibition initiation varied between and within individual patients with type 2 diabetes treated in primary care. Poor responders had the highest risk of cardiovascular events, therefore, more efforts are needed to develop personalized treatment plans for these patients.
评估 2 型糖尿病患者起始肾素-血管紧张素-醛固酮系统（RAAS）抑制后收缩压（SBP）和白蛋白尿（尿白蛋白肌酐比 [UACR]）反应的变异性，并评估反应变异性与心血管结局的相关性。
我们对 2007 年至 2013 年间开始接受 RAAS 抑制的 2 型糖尿病患者进行了一项观察性队列研究（n=1600）。患者来自荷兰的一般实践中确定。在 15 个月的随访期间评估 SBP 和 UACR 的个体反应。患者被分为：良好反应者（∆SBP<0mmHg 和 ∆UACR<0%）；中间反应者（∆SBP<0mmHg 和 ∆UACR>0%或 ∆SBP>0mmHg 和 ∆UACR<0%）；或不良反应者（∆SBP>0mmHg 和 ∆UACR>0%）。多变量 Cox 回归用于检验初始 RAAS 抑制反应与随后心血管结局之间的关系。
起始 RAAS 抑制后，SBP 平均变化为-13.2mmHg，UACR 中位数为-36.6%，个体间变异性较大，SBP[第 5 至 95 百分位数：48.5-20]和 UACR[第 5 至 95 百分位数：-87.6 至 171.4]均如此。共有 812 名患者（51%）为良好反应者，353 名患者（22%）SBP 反应良好但 UACR 反应不佳，268 名患者（17%）UACR 反应良好但 SBP 反应不佳，167 名患者（10%）反应不佳。与不良反应者相比，良好反应者心血管事件风险较低（危险比 0.51，95%置信区间 0.30-0.86；P=0.012）。
在初级保健中治疗的 2 型糖尿病患者中，起始 RAAS 抑制后 SBP 和 UACR 反应在个体之间和个体内存在差异。不良反应者心血管事件风险最高，因此需要更多努力为这些患者制定个性化治疗计划。
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