ACEI对单侧动脉粥样硬化性肾动脉狭窄老年患者肾功能的影响
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摘要
动脉粥样硬化性肾动脉狭窄(atherosclerotic renal artery stenosis,ARAS)是老年人继发性高血压的常见原因。血管紧张素转换酶抑制剂(angiotensin coverting enzyme inhibitors,ACEI)用于治疗肾血管性高血压效果优异,并且在众多降压药物中,ACEI是唯一既可以通过降压保护肾脏,又可以通过其他途径改善肾组织病变、降低蛋白尿的药物。对于双侧肾动脉狭窄或孤立肾肾动脉狭窄,ACEI是绝对禁忌。但对于单侧ARAS是否应用ACEI治疗一直存在争议,国内外相关报道很少。贝那普利(洛汀新?)是ACEI类中的典型药物,它几乎具有ACEI类药物的所有优势,且副反应发生率低,特别是对肾脏的保护作用明显,故本文以洛汀新?作为ACEI代表,初步探讨其对单侧动脉粥样硬化性肾动脉狭窄老年患者肾功能的影响。
目的:观察ACEI对单侧动脉粥样硬化性肾动脉狭窄(ARAS)老年患者肾功能的影响,探索单侧ARAS的有效药物治疗。
方法:根据临床表现和肾动脉造影结果筛选单侧ARAS患者共115例,分为洛汀新?组55例与非ACEI组60例。记录基础血压、血清肌酐,以CKD-EPI公式计算肾小球滤过率(GFR),记录入院时N-乙酰-β-氨基葡萄糖苷酶(NAG)。随访第一个月两周一次,此后每三个月一次,测量血压,化验血钾,并计算GFR,比较两组患者随访期间肾功能变化。
结果:两组患者基础资料无显著性差异(P>0.05)。平均随访15个月,洛汀新?组降压效果优于非ACEI组(P<0.05)。与基线相比,洛汀新?组GFR无明显变化[(80.73±16.707)ml·min~(-1)·(1.73 m~2)~(-1)比(81.06±12.231)ml·min~(-1)·(1.73 m~2)~(-1),P>0.05];ACEI组GFR下降明显[(81.49±14.486)ml·min~(-1)·(1.73 m~2)~(-1)比(79.84±14.648)ml·min~(-1)·(1.73 m~2)~(-1),P<0.01]。至观察末,非ACEI组GFR低于洛汀新?组[(79.84±14.648)ml·min~(-1)·(1.73 m~2)~(-1)比(81.06±12. 231)ml·min~(-1)·(1.73 m~2)~(-1),P<0.05]。非ACEI组GFR下降率(△GFR%)明显高于洛汀新?组(-9.694%±5.994%比0.261%±8.255%,P<0.01)。相关性分析显示,基础GFR、NAG与△GFR%显著相关(Pearson积距相关系数分别为0.573、-0.472,P<0.01)。
结论:1.应用ACEI治疗单侧ARAS所致高血压,降压效果理想,且对肾功能无显著影响,建议在监测肾功能的前提下,首选ACEI治疗ARAS。2.应用ACEI治疗单侧ARAS所致高血压,降压效果明显优于其他降压药物。3.NAG是评价早期肾脏损害最敏感的指标,建议无Scr及BUN改变的ARAS患者行此项检查,以警惕无临床症状及体征的肾脏病变。4.单侧ARAS患者出现NAG异常时,即提示已经存在早期肾脏损害,应用非ACEI类降压药物会导致肾功能下降,故应用时宜慎重。
An epidemiological screening showed that the average age of 77 yearsin the population, the renal artery stenosis (stenosis>60%) prevalence rate was 6.8%.Autopsy found that 27% of patients over 50 years suffered RAS(stenosis≥50%).There is 10.15% of kidney dialysis patients develop to endstage renal disease due to RAS. There are 25% of renal dysfunction in el-derly patients, associated with undiagnosed RAS. In adults, RAS is mainlyatherosclerosis caused. In western countries, 90% of the RAS is caused byatherosclerosis, whereas 72% of our country. If other organizations vessels (cerebral, coronary and peripheral vascular) suffer atherosclerosis, the occur-enceof an increased likelihood of RAS. The atherosclerotic renal artery ste-nosis(ARAS)mainly secondary tohypertension, proteinuria, severe cases can lead to end-stage renal disease.
Angiotensin converting enzyme inhibitor (ACEI)in the main mechanismfor the inhibition of the renin angiotensin aldosterone system (RAAS) and kallikrein-kinin system (KKS), this in double system produced by a varietyof vasodilators, antiproliferative, antithrombotic and anti-fibrosis synergistic, antagonistic too increased angiotensinⅡ(AnglotenslnⅡ, AngⅡ) of the har-mful effects, thereby protecting target organs. Hou Fanfan's ESBARI such studies in China show that the high tissue affinity angiotensin converting enzyme inhibitors can reduce the advanced chronic kidney disease patients developed end-stage renal failure to the risk that the only buck Baohu bot-h through kidneys, but also by other ways to improve the renal lesions, r-educe proteinuria drugs. So far, in improving endothelial function, angiote-nsin converting enzyme inhibitors are best than other antihypertensive drug-s (diuretics,βblockers, calcium antagonists).The results also suggested thatthe angiotensin converting enzyme inhibitors in improving the prognosis ofpatients the outstanding position, especially in patients with multiple athero-sclerotic disease in elderly patients is more respected.
For bilateral RAS or solitary kidney renal artery stenosis, ACEI is ab-solutely contraindicated. Unilateral RAS patients narrowkidneys perfusion p-ressure decline, plasma renin elevated, AngⅡincrease systemic vasoconstr- iction aroused hypertension, hypertension acting on contralateral kidney, thr-oughpressure diuresis make sodium excretion increase. However, AngⅡin-crease, its vasoconstriction reduce contralateral renal blood reduce GFR, in-fluence on adrenal cortex, promote aldosterone generate, promoting water sodium reabsorption above role and contralateral renal pressure diuretic eff-ects offset, water sodium balance rely system hypertension generated diure-tic role maintain, using ACEI treatment, although stenosis kidneys blood f-low reduce, GFR declined, contralateral kidney blood flow increased, GFR increase, application ACEI can effectively control blood pressure, prevent concurrency disease. However, it is controversial that whether angiotensin converting enzyme inhibitors should be used in unilateral atherosclerotic re-nal arterystenosis patients, because there are reports that angiotensin converting enzyme inhibitors in some cases cause severe renal insufficiency, littleresearch at home and abroad. Benazepril ( Lotensin? ) is typical of ACEI class of drug, it almost has all the benefits of ACEI drugs, and the low incidence of side effects, especially kidney protective effect , so this paper regard Lotensin? as ACEI representative to explore its unilateral atheroscle-rotic stenosis of renal artery in renal function in elderly patients.
Objective:ACEI observed in unilateral atherosclerotic renal artery ste-nosis (ARAS) of renal function in elderly patients, to explore an effective drug for treatment of unilateral ARAS.
Methods:Based on the clinical manifestations and results of screeningrenal arteriography in patients with a total of 115 cases of unilateral ARA-S divided into Lotensin? group of 55 patients and non-ACEI group of 60-cases.Record the baseline blood pressure,Scr,in order to calculate glomerularfiltration rate (GFR) with CKD-EPI formula, record the N-acetyl-β-glucosa-minidase (NAG) on admission. The first month of follow-up bi-weekly, on-ce every three months thereafter, measurement of blood pressure, serumpot-assiumtests, Scr, and calculate the GFR, patients were compared changes inrenal function during follow-up.
Results:The basis of information the two groups was no significant difference (P> 0.05). During the average follow-up 15 months, Lotensin? group is better than non-ACEI group in antihypertensive effect (P<0.05). Compared with baseline, Lotensin? group is no significant changes in GFR[(80.73±16.707)ml·min~(-1)·(1.73m~2)~(-1)vs(81.06±12.231)ml·min~(-1)·(1.73m~2)~(-1),P>0.05];ACEI group GFR decreased significantly[(81.49±14.486)ml·min~(-1)·(1.73m~2)~(-1)比(79.84±14.648)ml·min~(-1)·(1.73m~2)~(-1),P<0.01]. To observe the end of the non-ACEI group GFR less than Lotensin? group[(79.84±14.648)ml·min~(-1)·(1.73m2)~(-1)比(81.06±12.231)ml·min~(-1)·(1.73 m~2)~(-1),P<0.05]. Non-ACEI group GFR de-creased rate (△GFR%) was significantly higher than Lotensin? group(-9.694%±5.994%比0.261%±8.255%,P<0.01). Correlation analysis showed that ba-sed on GFR, NAG with△GFR% was significantly correlated (Pearson pr-oduct correlation coefficients were from 0.573, -0.472, P<0.01).
Conclusion:1. Using ACEI in the treatment of hypertension caused by un-ilateral ARAS, that the antihypertensive effect is ideal, and the renal func-tion has no significant changed. It is recommended to prefer ACEI in the treatment of ARAS with kidney function monitoring. 2. In the treatment ofhypertension caused by unilateral ARAS, ACEI is superior to other antihy-pertensive drugs. 3. NAG is the most sensitive indicators to assessment theearly renal damage, it is recommended to check it in kidney patients who-se Scr and BUN are no changed to guard against the kidney disease with no clinical symptoms and signs. 4.For patients with unilateral ARAS, whentheir NAG are abnormal, which prompted the early renal damage, applicat-ion of non-ACEI class of antihypertensive drugs can cause decreased kidn- ey function, so applications should carefully.
目的:观察ACEI对单侧动脉粥样硬化性肾动脉狭窄(ARAS)老年患者肾功能的影响,探索单侧ARAS的有效药物治疗。
方法:根据临床表现和肾动脉造影结果筛选单侧ARAS患者共115例,分为洛汀新?组55例与非ACEI组60例。记录基础血压、血清肌酐,以CKD-EPI公式计算肾小球滤过率(GFR),记录入院时N-乙酰-β-氨基葡萄糖苷酶(NAG)。随访第一个月两周一次,此后每三个月一次,测量血压,化验血钾,并计算GFR,比较两组患者随访期间肾功能变化。
结果:两组患者基础资料无显著性差异(P>0.05)。平均随访15个月,洛汀新?组降压效果优于非ACEI组(P<0.05)。与基线相比,洛汀新?组GFR无明显变化[(80.73±16.707)ml·min~(-1)·(1.73 m~2)~(-1)比(81.06±12.231)ml·min~(-1)·(1.73 m~2)~(-1),P>0.05];ACEI组GFR下降明显[(81.49±14.486)ml·min~(-1)·(1.73 m~2)~(-1)比(79.84±14.648)ml·min~(-1)·(1.73 m~2)~(-1),P<0.01]。至观察末,非ACEI组GFR低于洛汀新?组[(79.84±14.648)ml·min~(-1)·(1.73 m~2)~(-1)比(81.06±12. 231)ml·min~(-1)·(1.73 m~2)~(-1),P<0.05]。非ACEI组GFR下降率(△GFR%)明显高于洛汀新?组(-9.694%±5.994%比0.261%±8.255%,P<0.01)。相关性分析显示,基础GFR、NAG与△GFR%显著相关(Pearson积距相关系数分别为0.573、-0.472,P<0.01)。
结论:1.应用ACEI治疗单侧ARAS所致高血压,降压效果理想,且对肾功能无显著影响,建议在监测肾功能的前提下,首选ACEI治疗ARAS。2.应用ACEI治疗单侧ARAS所致高血压,降压效果明显优于其他降压药物。3.NAG是评价早期肾脏损害最敏感的指标,建议无Scr及BUN改变的ARAS患者行此项检查,以警惕无临床症状及体征的肾脏病变。4.单侧ARAS患者出现NAG异常时,即提示已经存在早期肾脏损害,应用非ACEI类降压药物会导致肾功能下降,故应用时宜慎重。
An epidemiological screening showed that the average age of 77 yearsin the population, the renal artery stenosis (stenosis>60%) prevalence rate was 6.8%.Autopsy found that 27% of patients over 50 years suffered RAS(stenosis≥50%).There is 10.15% of kidney dialysis patients develop to endstage renal disease due to RAS. There are 25% of renal dysfunction in el-derly patients, associated with undiagnosed RAS. In adults, RAS is mainlyatherosclerosis caused. In western countries, 90% of the RAS is caused byatherosclerosis, whereas 72% of our country. If other organizations vessels (cerebral, coronary and peripheral vascular) suffer atherosclerosis, the occur-enceof an increased likelihood of RAS. The atherosclerotic renal artery ste-nosis(ARAS)mainly secondary tohypertension, proteinuria, severe cases can lead to end-stage renal disease.
Angiotensin converting enzyme inhibitor (ACEI)in the main mechanismfor the inhibition of the renin angiotensin aldosterone system (RAAS) and kallikrein-kinin system (KKS), this in double system produced by a varietyof vasodilators, antiproliferative, antithrombotic and anti-fibrosis synergistic, antagonistic too increased angiotensinⅡ(AnglotenslnⅡ, AngⅡ) of the har-mful effects, thereby protecting target organs. Hou Fanfan's ESBARI such studies in China show that the high tissue affinity angiotensin converting enzyme inhibitors can reduce the advanced chronic kidney disease patients developed end-stage renal failure to the risk that the only buck Baohu bot-h through kidneys, but also by other ways to improve the renal lesions, r-educe proteinuria drugs. So far, in improving endothelial function, angiote-nsin converting enzyme inhibitors are best than other antihypertensive drug-s (diuretics,βblockers, calcium antagonists).The results also suggested thatthe angiotensin converting enzyme inhibitors in improving the prognosis ofpatients the outstanding position, especially in patients with multiple athero-sclerotic disease in elderly patients is more respected.
For bilateral RAS or solitary kidney renal artery stenosis, ACEI is ab-solutely contraindicated. Unilateral RAS patients narrowkidneys perfusion p-ressure decline, plasma renin elevated, AngⅡincrease systemic vasoconstr- iction aroused hypertension, hypertension acting on contralateral kidney, thr-oughpressure diuresis make sodium excretion increase. However, AngⅡin-crease, its vasoconstriction reduce contralateral renal blood reduce GFR, in-fluence on adrenal cortex, promote aldosterone generate, promoting water sodium reabsorption above role and contralateral renal pressure diuretic eff-ects offset, water sodium balance rely system hypertension generated diure-tic role maintain, using ACEI treatment, although stenosis kidneys blood f-low reduce, GFR declined, contralateral kidney blood flow increased, GFR increase, application ACEI can effectively control blood pressure, prevent concurrency disease. However, it is controversial that whether angiotensin converting enzyme inhibitors should be used in unilateral atherosclerotic re-nal arterystenosis patients, because there are reports that angiotensin converting enzyme inhibitors in some cases cause severe renal insufficiency, littleresearch at home and abroad. Benazepril ( Lotensin? ) is typical of ACEI class of drug, it almost has all the benefits of ACEI drugs, and the low incidence of side effects, especially kidney protective effect , so this paper regard Lotensin? as ACEI representative to explore its unilateral atheroscle-rotic stenosis of renal artery in renal function in elderly patients.
Objective:ACEI observed in unilateral atherosclerotic renal artery ste-nosis (ARAS) of renal function in elderly patients, to explore an effective drug for treatment of unilateral ARAS.
Methods:Based on the clinical manifestations and results of screeningrenal arteriography in patients with a total of 115 cases of unilateral ARA-S divided into Lotensin? group of 55 patients and non-ACEI group of 60-cases.Record the baseline blood pressure,Scr,in order to calculate glomerularfiltration rate (GFR) with CKD-EPI formula, record the N-acetyl-β-glucosa-minidase (NAG) on admission. The first month of follow-up bi-weekly, on-ce every three months thereafter, measurement of blood pressure, serumpot-assiumtests, Scr, and calculate the GFR, patients were compared changes inrenal function during follow-up.
Results:The basis of information the two groups was no significant difference (P> 0.05). During the average follow-up 15 months, Lotensin? group is better than non-ACEI group in antihypertensive effect (P<0.05). Compared with baseline, Lotensin? group is no significant changes in GFR[(80.73±16.707)ml·min~(-1)·(1.73m~2)~(-1)vs(81.06±12.231)ml·min~(-1)·(1.73m~2)~(-1),P>0.05];ACEI group GFR decreased significantly[(81.49±14.486)ml·min~(-1)·(1.73m~2)~(-1)比(79.84±14.648)ml·min~(-1)·(1.73m~2)~(-1),P<0.01]. To observe the end of the non-ACEI group GFR less than Lotensin? group[(79.84±14.648)ml·min~(-1)·(1.73m2)~(-1)比(81.06±12.231)ml·min~(-1)·(1.73 m~2)~(-1),P<0.05]. Non-ACEI group GFR de-creased rate (△GFR%) was significantly higher than Lotensin? group(-9.694%±5.994%比0.261%±8.255%,P<0.01). Correlation analysis showed that ba-sed on GFR, NAG with△GFR% was significantly correlated (Pearson pr-oduct correlation coefficients were from 0.573, -0.472, P<0.01).
Conclusion:1. Using ACEI in the treatment of hypertension caused by un-ilateral ARAS, that the antihypertensive effect is ideal, and the renal func-tion has no significant changed. It is recommended to prefer ACEI in the treatment of ARAS with kidney function monitoring. 2. In the treatment ofhypertension caused by unilateral ARAS, ACEI is superior to other antihy-pertensive drugs. 3. NAG is the most sensitive indicators to assessment theearly renal damage, it is recommended to check it in kidney patients who-se Scr and BUN are no changed to guard against the kidney disease with no clinical symptoms and signs. 4.For patients with unilateral ARAS, whentheir NAG are abnormal, which prompted the early renal damage, applicat-ion of non-ACEI class of antihypertensive drugs can cause decreased kidn- ey function, so applications should carefully.
引文
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[1]陈可冀,张国玺,吴青,等.我国近五年老年医学研究进展.中华老年医学杂志,2005,24(5):325-328.
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[9]O'Neil EA et al.(1992) Prevalence of ischemic nephropathy in patients with renal insufficiency.Am Surg 58: 485–490.
[10]Uzu T et al.(1997) Prevalence and predictors of renal artery stenosis in patients with myocardial infarction. Am J Kidney Dis 29: 733–738.
[11]Rimmer JM and Gennari FJ (1993) Atherosclerotic renovascular disease and progressive renal failure. Ann Intern Med 118: 712–719.
[12]Slovut DP and Olin JW (2004) Fibromuscular dysplasia.N Engl J Med 350: 1862–1871.
[13]Safian RD, Textor SC. Renal artery stenosis [J]. N Engl J Med, 2001, 344(6):431- 432.
[14]王芳,王梅,刘玉春,等.动脉粥样硬化性肾动脉狭窄的发病趋势[J].中华医学杂志,2005,85(39):2762-2766.
[15]Scoble J (1996). The epidemiology and clinical manifestations of atherosclerotic renal disease. In Renal Vascular Disease 303–314 (Eds Novick AC et al.) London: WB Saunders.
[16]Fan Fan Hou, Xun Zhang, Guo Hua Zhang, Di Xie, et al. Efficacy and safety of benazepril in patients with advanced chronic renal insufficiency (ESBARI): A randomized controlled trial. The New England Journal of Medicine, 2006, 12(354):131-140.
[17]Higashi Y, et al. Jam Coll Cardiol. 2000, 35:284-291.
[18]Losito A, Errico R, Santirosi P, et al. Long-term Follow-up of Atherosclerotic Renovascular Disease: Beneficial Effect of ACE Inhibition [J]. Nephrol Dial Transplant, 2005, 20(8):1604-1609.
[19]Schalekamp MA, Wenting GJ. Angiotensin converting enzyme inhibition in renowascular hypertension: failure of the stenotic kidney.Lancet, 1984, 25:464.
[20]Postma CT, Hoefagels WH, Barentsz JO, et al. Occlusion of unilateralstenosed renal arteries-relation to medical treatment. J Hum Hypertens, 1989:3:185-190.
[21]Arzilli F, Giovannetti R, Meola M, et al. ACE-inhibition vs. surgical treatment in the outcome of ischemic kidney of renovascular patients: a one year follow-up. High Blood Press, 1992, 1:47-50.
[22]MacDowall P , Kalra PA , O’Donoghue DJ , et al . Risk of morbidity from renovascular disease in elderly patients with congestive cardiac failure. Lancet, 1998, 352:13-16.
[23]Dworkin L D .Controversial Treatment of Atherosclerotic Renal Vascular Disease: The Cardiovascular Outcomes in Renal Atherosclerotic Lesions Trial[J].Hypertension,2006 ,48(3):350-356.
[24]Kidney Disease Outcomes Quality Initiative(K/DOQI). K/DOQI Clinical Practice Guidelines on Hypertension and Antihypertensive Agents in Chronic Kidney Disease [J].Am J Kidney Dis, 2004, 43(5 S 1):1-290.
[25]White CJ, Olin JW. Diagnosis and management of atherosclerotic rend artery stenosis: improving patient selection and outcomes. Nat Clin Pract Cardiovasc Med,2009-02-23.
[26]黄颂敏,欧三桃.高血压病肾损害的诊断及治疗.中华肾脏病杂志, 2005,21(10):566-568.
[27]李雪竹,严海东.尿β2微球蛋白、NAG测定对肾功能评价的意义及其与年龄的关系.中国医科大学学报,2006,35(3):314.