Institute for Health Research, Kaiser Permanente Colorado, Aurora, Colorado.
Divisions of Endocrinology, Metabolism and Diabetes and.
Clin J Am Soc Nephrol. 2018 May 7;13(5):727-734. doi: 10.2215/CJN.09510817. Epub 2018 Mar 23.
In individuals with diabetes, the comparative effectiveness of add-on antihypertensive medications added to an angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker on the risk of significant kidney events is unknown.
DESIGN, SETTING PARTICIPANTS, & MEASUREMENTS: We used an observational, multicenter cohort of 21,897 individuals with diabetes to compare individuals who added -blockers, dihydropyridine calcium channel blockers, loop diuretics, or thiazide diuretics to angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers. We examined the hazard of significant kidney events, cardiovascular events, and death using Cox proportional hazard models with propensity score weighting. The composite significant kidney event end point was defined as the first occurrence of a ≥30% decline in eGFR to an eGFR<60 ml/min per 1.73 m, initiation of dialysis, or kidney transplant. The composite cardiovascular event end point was defined as the first occurrence of hospitalization for acute myocardial infarction, acute coronary syndrome, stroke, or congestive heart failure; coronary artery bypass grafting; or percutaneous coronary intervention, and it was only examined in those free of cardiovascular disease at baseline.
Over a maximum of 5 years, there were 4707 significant kidney events, 1498 deaths, and 818 cardiovascular events. Compared with thiazide diuretics, hazard ratios for significant kidney events for -blockers, calcium channel blockers, and loop diuretics were 0.81 (95% confidence interval, 0.74 to 0.89), 0.67 (95% confidence interval, 0.58 to 0.78), and 1.19 (95% confidence interval, 1.00 to 1.41), respectively. Compared with thiazide diuretics, hazard ratios of mortality for -blockers, calcium channel blockers, and loop diuretics were 1.19 (95% confidence interval, 0.97 to 1.44), 0.73 (95% confidence interval, 0.52 to 1.03), and 1.67 (95% confidence interval, 1.31 to 2.13), respectively. Compared with thiazide diuretics, hazard ratios of cardiovascular events for -blockers, calcium channel blockers, and loop diuretics compared with thiazide diuretics were 1.65 (95% confidence interval, 1.39 to 1.96), 1.05 (95% confidence interval, 0.80 to 1.39), and 1.55 (95% confidence interval, 1.05 to 2.27), respectively.
Compared with thiazide diuretics, calcium channel blockers were associated with a lower risk of significant kidney events and a similar risk of cardiovascular events.
在糖尿病患者中，添加血管紧张素转换酶抑制剂或血管紧张素 II 受体阻滞剂的加用降压药物对严重肾脏事件风险的比较效果尚不清楚。
方法、设置参与者和测量方法：我们使用了一个观察性的、多中心队列，包含 21897 名糖尿病患者，比较了添加β受体阻滞剂、二氢吡啶类钙通道阻滞剂、袢利尿剂或噻嗪类利尿剂与血管紧张素转换酶抑制剂或血管紧张素 II 受体阻滞剂的患者。我们使用 Cox 比例风险模型和倾向评分加权法检查了严重肾脏事件、心血管事件和死亡的风险。严重肾脏事件的复合终点定义为 eGFR 下降≥30%至 eGFR<60 ml/min/1.73 m、开始透析或肾移植的首次发生。心血管复合事件终点定义为急性心肌梗死、急性冠脉综合征、中风或充血性心力衰竭、冠状动脉旁路移植术或经皮冠状动脉介入治疗的首次住院，仅在基线无心血管疾病的患者中进行检查。
在最长 5 年的时间内，发生了 4707 例严重肾脏事件、1498 例死亡和 818 例心血管事件。与噻嗪类利尿剂相比，β受体阻滞剂、钙通道阻滞剂和袢利尿剂的严重肾脏事件风险比分别为 0.81（95%置信区间，0.74 至 0.89）、0.67（95%置信区间，0.58 至 0.78）和 1.19（95%置信区间，1.00 至 1.41）。与噻嗪类利尿剂相比，β受体阻滞剂、钙通道阻滞剂和袢利尿剂的死亡率风险比分别为 1.19（95%置信区间，0.97 至 1.44）、0.73（95%置信区间，0.52 至 1.03）和 1.67（95%置信区间，1.31 至 2.13）。与噻嗪类利尿剂相比，β受体阻滞剂、钙通道阻滞剂和袢利尿剂的心血管事件风险比分别为 1.65（95%置信区间，1.39 至 1.96）、1.05（95%置信区间，0.80 至 1.39）和 1.55（95%置信区间，1.05 至 2.27）。
与噻嗪类利尿剂相比，钙通道阻滞剂与严重肾脏事件风险降低相关，且与心血管事件风险相似。
