Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece.
Department of Renal Medicine, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.
J Hum Hypertens. 2021 Jun;35(6):499-509. doi: 10.1038/s41371-021-00504-9. Epub 2021 Mar 2.
Management of hypertension and albuminuria are considered among the primary goals of treatment to slow the progression of chronic kidney disease (CKD). Renin-angiotensin system (RAS) blockers, i.e., angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) are the main drugs to achieve these goals. Seminal studies have showed that RAS blockers present significant renoprotective effects in CKD patients with very high albuminuria. In post hoc analyses of such trials, these renoprotective effects appeared more robust in patients with more advanced CKD. However, randomized trials specifically addressing whether RAS blockers should be initiated or maintained in patients with advanced CKD are scarce and do not include subjects with normoalbuminuria, thus, many clinicians are unconvinced for the beneficial effects of RAS blockade in these patients. Further, the fear of hyperkalemia or acute renal decline is another factor due to which RAS blockers are usually underprescribed and are easily discontinued in patients with more advanced CKD; i.e., those in Stages 4 and 5. This review summarizes evidence from the literature regarding the use of RAS blockers in patients with advanced CKD.
高血压和白蛋白尿的管理被认为是减缓慢性肾脏病（CKD）进展的治疗主要目标之一。肾素-血管紧张素系统（RAS）阻滞剂，即血管紧张素转换酶抑制剂（ACEI）或血管紧张素受体阻滞剂（ARB），是实现这些目标的主要药物。重要研究表明，RAS 阻滞剂在白蛋白尿非常高的 CKD 患者中具有显著的肾脏保护作用。在这些试验的事后分析中，这些肾脏保护作用在 CKD 更晚期的患者中更为显著。然而，专门针对 RAS 阻滞剂是否应在晚期 CKD 患者中开始或维持使用的随机试验很少，并且不包括正常白蛋白尿患者，因此，许多临床医生并不相信 RAS 阻断对这些患者的有益作用。此外，担心高钾血症或急性肾功能下降是另一个因素，由于这个原因，RAS 阻滞剂通常在 CKD 更晚期患者中处方不足，并且很容易被停用；即，那些处于第 4 期和第 5 期的患者。这篇综述总结了文献中关于 RAS 阻滞剂在晚期 CKD 患者中应用的证据。
