终末期肾病患者主动脉僵硬度非药物干预的系统评价与荟萃分析
A Systematic Review and Meta-analysis of Nonpharmacologic-based Interventions for Aortic Stiffness in End-Stage Renal Disease.
作者信息
Rodriguez Rosendo A, Hae Richard, Spence Matthew, Shea Beverley, Agharazii Mohsen, Burns Kevin D
机构信息
Department of Medicine, The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada.
Division of Nephrology, Kidney Research Centre, University of Ottawa, Ottawa, Ontario, Canada.
出版信息
Kidney Int Rep. 2019 May 22;4(8):1109-1121. doi: 10.1016/j.ekir.2019.05.011. eCollection 2019 Aug.
INTRODUCTION
Increased carotid-femoral pulse wave velocity (cf-PWV) in end-stage renal disease (ESRD) indicates enhanced aortic stiffness and mortality risk. We conducted a systematic review and meta-analysis of nonpharmacologic interventions in adults with ESRD to determine their effects on cf-PWV, systolic blood pressure (SBP), and intervention-associated adverse events.
METHODS
MEDLINE, EMBASE, and EBM databases were searched. Study screening, selection, data collection, and methodological quality assessments were performed by 2 independent reviewers. Pooled-effect estimates from mean differences and 95% confidence intervals (CIs) were calculated using random effect models.
RESULTS
A total of 2166 subjects with ESRD from 33 studies (17 randomized; 16 nonrandomized) were included. Four intervention-comparator pairs were meta-analyzed. Quality of evidence ranged from very low to moderate. Kidney transplantation decreased cf-PWV (-0.70 m/s; CI: -1.3 to -0.11; = 0.02) and SBP (-8.3 mm Hg; CI: -13.2 to -3.3; < 0.001) over pretransplantation. In randomized trials, control of fluid overload by bio-impedance reduced cf-PWV (-1.90 m/s; CI: -3.3 to -0.5); = 0.02) and SBP (-4.3 mm Hg; CI: -7.7 to -0.93); = 0.01) compared with clinical assessment alone. Cross-sectional studies also demonstrated significantly lower cf-PWV and SBP in normovolemia compared with hypervolemia ( ≤ 0.01). Low calcium dialysate decreased cf-PWV (-1.70 m/s; CI: -2.4 to -1.0; < 0.00001) without affecting SBP (-1.6 mm Hg; CI: -8.9 to 5.8; = 0.61). Intradialytic exercise compared with no exercise reduced cf-PWV (-1.13 m/s; CI: -2.2 to -0.03; = 0.04), but not SBP (+0.5 mm Hg; CI: -9.5 to 10.4); = 0.93).
CONCLUSIONS
Several nonpharmacologic interventions effectively decrease aortic stiffness in ESRD. The impact of these interventions on cardiovascular outcomes and mortality risk reduction in ESRD requires further study.
引言
终末期肾病（ESRD）患者的颈动脉-股动脉脉搏波速度（cf-PWV）升高表明主动脉僵硬度增加及死亡风险升高。我们对ESRD成年患者的非药物干预措施进行了系统评价和荟萃分析，以确定其对cf-PWV、收缩压（SBP）及干预相关不良事件的影响。
方法
检索MEDLINE、EMBASE和循证医学数据库。由2名独立的审阅者进行研究筛选、选择、数据收集及方法学质量评估。使用随机效应模型计算平均差和95%置信区间（CI）的合并效应估计值。
结果
共纳入来自33项研究（17项随机对照研究；16项非随机对照研究）的2166例ESRD患者。对4组干预-对照配对进行了荟萃分析。证据质量范围从极低到中等。肾移植术后cf-PWV较移植前降低（-0.70 m/s；CI：-1.3至-0.11；P = 0.02），SBP降低（-8.3 mmHg；CI：-13.2至-3.3；P < 0.001）。在随机对照试验中，与单纯临床评估相比，通过生物电阻抗控制液体超负荷可降低cf-PWV（-1.90 m/s；CI：-3.3至-0.5；P = 0.02）和SBP（-4.3 mmHg；CI：-7.7至-0.93；P = 0.01）。横断面研究也显示，与高血容量相比，正常血容量时cf-PWV和SBP显著降低（P≤0.01）。低钙透析液可降低cf-PWV（-1.70 m/s；CI：-2.4至-1.0；P < 0.00001），但不影响SBP（-1.6 mmHg；CI：-8.9至5.8；P = 0.61）。与不运动相比，透析期间运动可降低cf-PWV（-1.13 m/s；CI：-2.2至-0.03；P = 0.04），但不影响SBP（+0.5 mmHg；CI：-9.5至10.4；P = 0.93）。
结论
几种非药物干预措施可有效降低ESRD患者的主动脉僵硬度。这些干预措施对ESRD患者心血管结局及降低死亡风险的影响有待进一步研究。
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