Wang Kanran, Hu Jinbo, Luo Ting, Wang Yue, Yang Shumin, Qing Hua, Cheng Qingfeng, Li Qifu
Department of Endocrinology, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China.
Department of Endocrinology, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China,
Kidney Blood Press Res. 2018;43(3):768-779. doi: 10.1159/000489913. Epub 2018 May 22.
BACKGROUND/AIMS: Whether angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARB) could benefit patients with diabetes and albuminuria remains controversial. A systematic review and meta-analysis were conducted to answer this question by comparing ACE inhibitors or ARB with placebo among these patients.
In this meta-analysis, electronic data sources (Medline, the Cochrane Collaboration, and EMBASE) were searched. Randomized controlled trials (RCTs) comparing ACE inhibitors or ARB with placebo in subjects with diabetes and albuminuria (defined as urinary albumin-to-creatinine ratio, UACR≥30mg/g Cr) were included. Outcomes parameters were all-cause mortality, end stage renal disease (ESRD), doubling of serum creatinine levels, and cardiovascular events (CV).
Twenty-six RCTs (including 20 for ACE inhibitors and 6 for ARB) were included, comprising 10378 participants with diabetes and albuminuria. Compared to placebo, treatment with ACE inhibitors or ARBs did not reduce all-cause mortality or CV. For renal outcomes, ARBs significantly reduced the risk of ESRD by 23% (odds ratio 0.77, 95%CI 0.65-0.92), while ACE inhibitors were not associated with a decreased risk of ESRD (0.69, 0.43-1.10). Both ACE inhibitors and ARBs reduced the risk of doubling of the serum creatinine level (0.60, 0.39-0.91 for ACE inhibitors; 0.75, 0.64-0.88 for ARBs), and subgroup analyses for patients with macroalbuminuria or microalbuminuria showed similar results.
In patients with diabetes and albuminuria, ARBs reduced risks of ESRD and doubling of the serum creatinine level. ACE inhibitors and ARBs failed to reduce all-cause mortality and CV. Based on the renoprotective effects, ARBs may be preferred for diabetic patients with albuminuria.
背景/目的：血管紧张素转换酶（ACE）抑制剂或血管紧张素II受体阻滞剂（ARB）是否能使糖尿病和蛋白尿患者获益仍存在争议。通过比较这些患者中ACE抑制剂或ARB与安慰剂，进行了一项系统评价和荟萃分析来回答这个问题。
在这项荟萃分析中，检索了电子数据源（Medline、Cochrane协作网和EMBASE）。纳入了比较ACE抑制剂或ARB与安慰剂在糖尿病和蛋白尿患者（定义为尿白蛋白与肌酐比值，UACR≥30mg/g Cr）中的随机对照试验（RCT）。结局参数为全因死亡率、终末期肾病（ESRD）、血清肌酐水平翻倍以及心血管事件（CV）。
纳入了26项RCT（包括20项关于ACE抑制剂的和6项关于ARB的），共10378例糖尿病和蛋白尿患者。与安慰剂相比，使用ACE抑制剂或ARB治疗并未降低全因死亡率或心血管事件。对于肾脏结局，ARB显著降低了23%的ESRD风险（比值比0.77，95%CI为0.65 - 0.92），而ACE抑制剂与ESRD风险降低无关（0.69，0.43 - 1.10）。ACE抑制剂和ARB均降低了血清肌酐水平翻倍的风险（ACE抑制剂为0.60，0.39 - 0.91；ARB为0.75，0.64 - 0.88），对大量蛋白尿或微量蛋白尿患者的亚组分析显示了相似结果。
在糖尿病和蛋白尿患者中，ARB降低了ESRD风险和血清肌酐水平翻倍的风险。ACE抑制剂和ARB未能降低全因死亡率和心血管事件。基于肾脏保护作用，ARB可能更适合患有蛋白尿的糖尿病患者。
