螺内酯在心力衰竭患者中的应用致高钾血症和急性肾损伤。
Hyperkalemia and Acute Kidney Injury with Spironolactone Use Among Patients with Heart Failure.
机构信息
Johns Hopkins University Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD; Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, MD.
Johns Hopkins University Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD; Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, MD.
出版信息
Mayo Clin Proc. 2020 Nov;95(11):2408-2419. doi: 10.1016/j.mayocp.2020.03.035.
OBJECTIVE
To quantify the risk of hyperkalemia and acute kidney injury (AKI) when spironolactone use is added on to loop diuretic use among patients with heart failure, and to evaluate whether the risk is modified by level of kidney function.
METHODS
We identified 17,110 patients with heart failure treated with loop diuretics between January 1, 2004, and December 31, 2016 within the Geisinger Health System. We estimated the incidence of hyperkalemia and AKI associated with spironolactone initiation, and used target trial emulation methods to minimize confounding by indication.
RESULTS
During a mean follow-up of 134 mo, 3229 of 17,110 patients (18.9%) initiated spironolactone. Incidence rates of hyperkalemia and AKI in patients using spironolactone with a loop diuretic were 2.9 and 10.1 events per 1000 person-months, respectively. In propensity score-matched analyses, spironolactone initiation was associated with higher hyperkalemia and AKI risk compared with loop alone (hazard ratio, 1.69; 95% CI, 1.35 to 2.10; P<.001, and hazard ratio, 1.12; 95% CI, 1.00 to 1.26; P=.04, respectively). There were no differences in the relative risk of either outcome associated with spironolactone by level of kidney function.
CONCLUSION
The addition of spironolactone to loop diuretics in patients with heart failure was associated with higher risk of hyperkalemia and AKI; these risks must be weighed against the potential benefits of spironolactone.
目的
量化心力衰竭患者在使用袢利尿剂的基础上加用螺内酯时发生高钾血症和急性肾损伤（AKI）的风险，并评估该风险是否受肾功能水平的影响。
方法
我们在 2004 年 1 月 1 日至 2016 年 12 月 31 日期间在 Geisinger 健康系统中确定了 17110 例接受袢利尿剂治疗的心力衰竭患者。我们估计了与螺内酯起始相关的高钾血症和 AKI 的发生率，并使用目标试验模拟方法尽量减少指示性混杂。
结果
在平均 134 个月的随访期间，17110 例患者中有 3229 例（18.9%）开始使用螺内酯。使用螺内酯联合袢利尿剂的患者中高钾血症和 AKI 的发生率分别为每 1000 人月 2.9 和 10.1 例。在倾向评分匹配分析中，与单独使用袢利尿剂相比，螺内酯起始与更高的高钾血症和 AKI 风险相关（风险比，1.69；95%置信区间，1.35 至 2.10；P<.001，和风险比，1.12；95%置信区间，1.00 至 1.26；P=.04，分别）。肾功能水平对螺内酯相关两种结局的相对风险无差异。
结论
心力衰竭患者在使用袢利尿剂的基础上加用螺内酯与更高的高钾血症和 AKI 风险相关；必须权衡螺内酯的潜在益处和这些风险。
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