肾素-血管紧张素系统抑制剂在非蛋白尿性慢性肾脏病中的心脏效应
Cardiac Effects of Renin-Angiotensin System Inhibitors in Nonproteinuric CKD.
作者信息
Shulman Rachel S, Yang Wei, Cohen Debbie L, Reese Peter P, Cohen Jordana B
机构信息
Renal-Electrolyte and Hypertension Division (R.S.S., D.L.C., P.P.R., J.B.C.), Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
Department of Biostatistics, Epidemiology, and Informatics (W.Y., P.P.R., J.B.C.), Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
出版信息
Hypertension. 2024 Oct;81(10):2082-2090. doi: 10.1161/HYPERTENSIONAHA.124.23184. Epub 2024 Aug 1.
BACKGROUND
In contrast to proteinuric chronic kidney disease (CKD), the relative cardioprotective benefits of antihypertensive medications in nonproteinuric CKD are unknown. We examined long-term cardiovascular outcomes and mortality in patients with nonproteinuric CKD treated with renin-angiotensin system inhibitors (RASIs) versus other antihypertensive medications.
METHODS
Among participants of the CRIC study (Chronic Renal Insufficiency Cohort) without proteinuria, we used intention-to-treat analyses with inverse probability of treatment weighting and Cox proportional hazards modeling to determine the association of RASIs versus other antihypertensive medications with a composite cardiovascular outcome (myocardial infarction, stroke, heart failure hospitalization, and death) and mortality. Secondary analyses included per-protocol analyses accounting for continuous adherence and time-updated analyses accounting for the proportion of time using RASIs during follow-up.
RESULTS
A total of 2806 participants met the inclusion criteria. In the intention-to-treat analyses, RASIs versus other antihypertensive medications were not associated with an appreciable difference in cardiovascular events (adjusted hazard ratio [aHR], 0.94 [95% CI, 0.80-1.11]) or mortality (aHR, 1.06 [95% CI, 0.88-1.28]). In the per-protocol analyses, RASIs were associated with a lower risk of adverse cardiovascular events (aHR, 0.78 [95% CI, 0.63-0.97]) and mortality (aHR, 0.64 [95% CI, 0.48-0.85]). Similarly, in the time-updated analyses, a higher proportion of RASI use over time was associated with a lower mortality risk (aHR, 0.33 [95% CI, 0.14-0.86]).
CONCLUSIONS
Among individuals with nonproteinuric CKD, after accounting for time-updated use, RASIs are associated with fewer cardiovascular events and a lower mortality risk compared with other antihypertensive medications. Patients with nonproteinuric CKD may benefit from prioritizing RASIs for hypertension management.
背景
与蛋白尿性慢性肾脏病（CKD）不同，抗高血压药物在非蛋白尿性CKD中的相对心脏保护益处尚不清楚。我们研究了使用肾素-血管紧张素系统抑制剂（RASI）与其他抗高血压药物治疗的非蛋白尿性CKD患者的长期心血管结局和死亡率。
方法
在慢性肾功能不全队列（CRIC）研究中无蛋白尿的参与者中，我们采用意向性分析、治疗权重逆概率法和Cox比例风险模型，以确定RASI与其他抗高血压药物与复合心血管结局（心肌梗死、中风、心力衰竭住院和死亡）及死亡率之间的关联。次要分析包括考虑持续依从性的符合方案分析，以及考虑随访期间使用RASI时间比例的时间更新分析。
结果
共有2806名参与者符合纳入标准。在意向性分析中，RASI与其他抗高血压药物相比，在心血管事件（校正风险比[aHR]，0.94[95%CI，0.80-1.11]）或死亡率（aHR，1.06[95%CI，0.88-1.28]）方面无明显差异。在符合方案分析中，RASI与不良心血管事件风险较低（aHR，0.78[95%CI，0.63-0.97]）和死亡率较低（aHR，0.64[95%CI，0.48-0.85]）相关。同样，在时间更新分析中，随着时间推移使用RASI的比例越高，死亡风险越低（aHR，0.33[95%CI，0.14-0.86]）。
结论
在非蛋白尿性CKD患者中，在考虑时间更新使用情况后，与其他抗高血压药物相比，RASI与较少的心血管事件和较低的死亡风险相关。非蛋白尿性CKD患者可能优先使用RASI进行高血压管理而获益。
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