Kung Chin-Wei, Lin Yi-Chih, Tseng Chi-Shin, Chou Yu-Hsiang
Center for Drug Evaluation, Taipei City, Taiwan.
Renal Division, Department of Internal Medicine, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei City, Taiwan.
Nephron. 2024;148(11-12):744-754. doi: 10.1159/000540305. Epub 2024 Jul 22.
The blockade of the renin-angiotensin system (RAS) has a beneficial effect on reducing the levels of proteinuria and blood pressure in patients with chronic kidney disease (CKD) and reduces the risk of developing end-stage kidney disease in CKD patients. Nonetheless, a debate persists regarding the impact of RAS inhibitors on outcomes such as mortality and graft survival in renal transplant patients. To assess the effect of RAS inhibitors on graft recipients in the past decade, we conducted a systematic review and meta-analysis.
We searched Embase, PubMed, and the Cochrane Central Register of Clinical Trials from January 1, 2012, to August 1, 2022. We included 14 articles, comprising 5 randomized controlled trials (RCTs) and 9 cohort studies, including 45,377 patients. These studies compared patient or graft survival between an RAS inhibitor treatment arm and a control arm.
The meta-analysis revealed that RAS blockade was significantly associated with lower mortality in cohort studies (risk ratio [RR] = 0.66, 95% confidence interval [CI]: 0.55-0.79), reduced allograft loss in cohort studies (RR = 0.62, 95% CI: 0.54-0.71), and significant changes in systolic blood pressure in RCTs. Subgroup analysis of the groups of interest (interventions involving RAS blockade, follow-up period of ≥5 years) showed consistently reduced mortality (RR = 0.67, 95% CI: 0.56-0.81) and reduced allograft loss (RR = 0.61, 95% CI: 0.54-0.70).
Our results demonstrated that the application of RAS blockade among renal transplant recipients was associated with lower mortality and allograft loss in cohort studies but not in RCTs. More powered clinical trials are needed to evaluate the effects of RAS blockade in renal transplant recipients.
肾素-血管紧张素系统（RAS）阻滞剂对降低慢性肾脏病（CKD）患者的蛋白尿水平和血压具有有益作用，并降低CKD患者发生终末期肾病的风险。尽管如此，关于RAS抑制剂对肾移植患者死亡率和移植物存活等结局的影响仍存在争议。为评估过去十年中RAS抑制剂对移植物受者的影响，我们进行了一项系统评价和荟萃分析。
我们检索了2012年1月1日至2022年8月1日期间的Embase、PubMed和Cochrane临床试验中心注册库。我们纳入了14篇文章，包括5项随机对照试验（RCT）和9项队列研究，共45377例患者。这些研究比较了RAS抑制剂治疗组和对照组之间的患者或移植物存活率。
荟萃分析显示，在队列研究中，RAS阻断与较低的死亡率显著相关（风险比[RR]=0.66，95%置信区间[CI]：0.55-0.79），在队列研究中同种异体移植物丢失减少（RR=0.62，95%CI：0.54-0.71），在RCT中收缩压有显著变化。对感兴趣的组（涉及RAS阻断的干预措施，随访期≥5年）进行亚组分析显示，死亡率持续降低（RR=0.67，95%CI：0.56-0.81），同种异体移植物丢失减少（RR=0.61，95%CI：0.54-0.70）。
我们的结果表明，在队列研究中，肾移植受者应用RAS阻断与较低的死亡率和同种异体移植物丢失相关，但在RCT中并非如此。需要更多有力的临床试验来评估RAS阻断对肾移植受者的影响。
