Division of Nephrology, Department of Medicine, University of Maryland, School of Medicine, Baltimore, MD.
University of Hawaii John A. Burns School of Medicine, Honolulu, HI.
Am J Kidney Dis. 2018 Dec;72(6):873-884. doi: 10.1053/j.ajkd.2018.06.010. Epub 2018 Sep 7.
Multiple clinical trials have demonstrated that renin-angiotensin system (RAS) blockade with either angiotensin-converting enzyme inhibitors or angiotensin receptor blockers effectively reduces chronic kidney disease (CKD) progression. However, most clinical trials excluded participants with advanced CKD (ie, estimated glomerular filtration rate [eGFR]<30mL/min/1.73m). It is acknowledged that initiation of RAS blockade is often associated with an acute reduction in eGFR, which is thought to be functional, but may result in long-term preservation of kidney function through the reductions in glomerular intracapillary pressure conferred by these agents. In this National Kidney Foundation-Kidney Disease Outcomes Quality Initiative (NKF-KDOQI) report, we discuss the controversies regarding use of RAS blockade in patients with advanced kidney disease. We review available published data on this topic and provide perspective on the impact of RAS blockade on changes in eGFRs and potassium levels. We conclude that more research is needed to evaluate the therapeutic index of RAS blockade in patients with advanced CKD.
多项临床试验已经证明，血管紧张素转换酶抑制剂或血管紧张素受体阻滞剂的肾素-血管紧张素系统（RAS）阻断可有效减缓慢性肾脏病（CKD）的进展。然而，大多数临床试验排除了晚期 CKD（即估算肾小球滤过率[eGFR]<30mL/min/1.73m）患者。人们承认，RAS 阻断的启动通常与 eGFR 的急性下降有关，这被认为是功能性的，但通过这些药物降低肾小球内压，可能导致长期保留肾功能。在这份美国国家肾脏基金会-肾脏病预后质量倡议（NKF-KDOQI）报告中，我们讨论了在晚期肾脏病患者中使用 RAS 阻断的争议。我们回顾了这一主题的现有已发表数据，并就 RAS 阻断对 eGFR 和血钾水平变化的影响提供了观点。我们的结论是，需要进一步研究来评估 RAS 阻断在晚期 CKD 患者中的治疗指数。
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