Kim Jong Yeob, Steingroever Johanna, Lee Keum Hwa, Oh Jun, Choi Min Jae, Lee Jiwon, Larkins Nicholas G, Schaefer Franz, Hong Sung Hwi, Jeong Gwang Hun, Shin Jae Il, Kronbichler Andreas
Yonsei University College of Medicine, Seoul 03722, Korea.
Department of Pediatric Nephrology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20251 Hamburg, Germany.
J Clin Med. 2020 Feb 1;9(2):394. doi: 10.3390/jcm9020394.
Patients with chronic kidney disease (CKD) have altered physiologic processes, which result in different treatment outcomes compared with the general population. We aimed to systematically evaluate the efficacy of clinical interventions in reducing mortality of patients with CKD. We searched PubMed, MEDLINE, Embase, and Cochrane Database of Systematic Reviews for meta-analyses of randomized controlled trials (RCT) or observational studies (OS) studying the effect of treatment on all-cause mortality of patients with CKD. The credibility assessment was based on the random-effects summary estimate, heterogeneity, 95% prediction intervals, small study effects, excess significance, and credibility ceilings. Ninety-two articles yielded 130 unique meta-analyses. Convincing evidence from OSs supported mortality reduction with three treatments: angiotensin-converting-enzyme inhibitors or angiotensin II receptor blockers for patients not undergoing dialysis, warfarin for patients with atrial fibrillation not undergoing dialysis, and (at short-term) percutaneous coronary intervention compared to coronary artery bypass grafting for dialysis patients. Two treatment comparisons were supported by highly credible evidence from RCTs in terms of all-cause mortality. These were high-flux hemodialysis (HD) versus low-flux HD as a maintenance HD method and statin versus less statin or placebo for patients not undergoing dialysis. Most significant associations identified in OSs failed to be replicated in RCTs. Associations of high credibility from RCTs were in line with current guidelines. Given the heterogeneity of CKD, it seems hard to assume mortality reductions based on findings from OSs.
慢性肾脏病（CKD）患者的生理过程发生了改变，与普通人群相比，其治疗结果也有所不同。我们旨在系统评价临床干预措施降低CKD患者死亡率的疗效。我们检索了PubMed、MEDLINE、Embase和Cochrane系统评价数据库，以查找关于治疗对CKD患者全因死亡率影响的随机对照试验（RCT）或观察性研究（OS）的荟萃分析。可信度评估基于随机效应汇总估计、异质性、95%预测区间、小研究效应、过度显著性和可信度上限。92篇文章产生了130项独特的荟萃分析。来自观察性研究的令人信服的证据支持三种治疗方法可降低死亡率：未接受透析的患者使用血管紧张素转换酶抑制剂或血管紧张素II受体阻滞剂，未接受透析的房颤患者使用华法林，以及（短期）透析患者经皮冠状动脉介入治疗与冠状动脉旁路移植术相比。就全因死亡率而言，两项治疗比较得到了来自随机对照试验的高度可信证据的支持。这两种情况分别是作为维持性血液透析方法的高通量血液透析（HD）与低通量HD，以及未接受透析的患者使用他汀类药物与较少使用他汀类药物或安慰剂相比。观察性研究中确定的大多数显著关联未能在随机对照试验中得到重复。来自随机对照试验的高可信度关联与当前指南一致。鉴于CKD的异质性，似乎很难根据观察性研究的结果推断死亡率会降低。
