Lin Donna Shu-Han, Lin Fang-Ju, Lin Yu-Sheng, Lee Jen-Kuang, Lin Yen-Hung
Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.
Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Hsin-Chu Branch, Hsinchu, Taiwan.
Eur J Heart Fail. 2023 Jan;25(1):98-107. doi: 10.1002/ejhf.2740. Epub 2022 Dec 11.
Mineralocorticoid receptor antagonists (MRAs) have been shown to provide survival benefits in patients with heart failure; however, MRA use in patients with chronic kidney disease has been limited by safety concerns. The effects of MRAs on outcomes in patients with end-stage renal disease (ESRD) and heart failure remain unknown. The aim of this study was to evaluate the effects of MRAs on cardiovascular outcomes in patients with heart failure under maintenance dialysis in a real-world setting.
A retrospective cohort study was conducted by collecting data from the Taiwan National Health Insurance Research Database (NHIRD). Patients diagnosed with heart failure and ESRD and who started maintenance dialysis between 1 January 2001 and 31 December 2013 were identified. Patients were grouped according to MRA prescription. The outcomes of interest included cardiovascular (CV) death, hospitalization for heart failure (HHF), all-cause mortality, acute myocardial infarction (AMI), ischaemic stroke, any coronary revascularization procedures, and new-onset hyperkalaemia. Propensity score matching was performed at a 1:3 ratio between MRA users and non-users to minimize selection bias. A total of 50 872 patients who satisfied our inclusion and exclusion criteria were identified. After 1:3 matching, 2176 patients were included in the MRA group, and 6528 patients were included in the non-MRA group. The risk of CV death was significantly lower among patients who received MRAs than those who did not (hazard ratio [HR] 0.88, 95% confidence interval [CI] 0.80-0.95), as was the risk of all-cause mortality (HR 0.88, 95% CI 0.83-0.94). Reductions in the risks of CV death and all-cause mortality were more prominent among patients undergoing haemodialysis and those with coronary artery disease.
In patients undergoing regular dialysis who are diagnosed with heart failure, the use of MRAs is associated with lower risks of all-cause mortality and CV death. The benefits of MRA treatment in heart failure may persist in patients with ESRD. Further investigations through randomized controlled trials are needed to assess the efficacy and safety of MRAs in this high-risk population.
盐皮质激素受体拮抗剂（MRAs）已被证明能为心力衰竭患者带来生存益处；然而，慢性肾病患者使用MRAs一直受到安全性问题的限制。MRAs对终末期肾病（ESRD）合并心力衰竭患者预后的影响尚不清楚。本研究的目的是在真实世界环境中评估MRAs对维持性透析的心力衰竭患者心血管结局的影响。
通过从台湾国民健康保险研究数据库（NHIRD）收集数据进行一项回顾性队列研究。确定了2001年1月1日至2013年12月31日期间被诊断为心力衰竭和ESRD并开始维持性透析的患者。根据MRAs处方对患者进行分组。感兴趣的结局包括心血管（CV）死亡、因心力衰竭住院（HHF）、全因死亡率、急性心肌梗死（AMI）、缺血性中风、任何冠状动脉血运重建手术以及新发高钾血症。在MRAs使用者和非使用者之间以1:3的比例进行倾向得分匹配，以尽量减少选择偏倚。共确定了50872名符合我们纳入和排除标准的患者。经过1:3匹配后，MRAs组纳入2176名患者，非MRAs组纳入6528名患者。接受MRAs治疗的患者发生CV死亡的风险显著低于未接受治疗的患者（风险比[HR]0.88，95%置信区间[CI]0.80 - 0.95），全因死亡率风险也是如此（HR 0.88，95%CI 0.83 - 0.94）。在接受血液透析的患者和患有冠状动脉疾病的患者中，CV死亡风险和全因死亡率的降低更为显著。
在被诊断为心力衰竭的定期透析患者中，使用MRAs与全因死亡率和CV死亡风险较低相关。MRAs治疗心力衰竭的益处可能在ESRD患者中持续存在。需要通过随机对照试验进行进一步研究，以评估MRAs在这一高危人群中的疗效和安全性。
