非糖尿病慢性肾脏病患者醛固酮逃逸的发生率及影响因素

Incidence and influencing factors of aldosterone breakthrough during therapy with angiotensin II receptor blockers alone, or combined with angiotensin- converting enzyme inhibitors in patientswith non-diabetic nephropathy

目的研究非糖尿病慢性肾脏病（CKD）患者醛固酮逃逸的发生率及相关影响因素。方法选择非糖尿病CKD患者144例，予血管紧张素Ⅱ受体拮抗剂（ARB）或ARB联合血管紧张素转化酶抑制剂（ACEI）治疗12个月，根据治疗前后醛固酮浓度的变化，确定是否发生醛固酮逃逸。结果肾素-血管紧张素-醛固酮系统抑制剂（RASI）治疗6个月时醛固酮逃逸的发生率为14．58％，治疗12个月时醛固酮逃逸的发生率显著升高（27．08％，P=0．009）。以治疗前水平为基线值，醛固酮逃逸的患者24h尿蛋白量与基线值的差值显著小于未发生逃逸的患者（P〈0．05），eGFR的差值也显著大于未发生逃逸的患者（P〈0．01）。尿蛋白基线值（OR=3．643，P=0．073）、eGFR基线值（OR=0．980，P=0．025）与RASI治疗12个月醛固酮逃逸的发生相关；eGFR基线值（OR=0．980，P=0．025）是醛固酮逃逸的独立预测因素。结论部分非糖尿病CKD患者在RASI治疗后出现醛固酮逃逸，醛固酮逃逸的发生率随RASI治疗时间延长呈升高趋势。eGFR基线值是醛固酮逃逸发生的独立预测因素。醛固酮逃逸可能影响RASI减少蛋白尿和保护肾功能的治疗效果。

Objective To investigate the incidence and influencing factors of aldosterone breakthrough during therapy with angiotensin II receptor blockers （ARB） alone, or combined with angiotensin- converting enzyme inhibitors （ACEI） in Chinese patients with non- diabetic nephropathy. Methods A total of 144 patients with non-diabetic nephropathy were treated with ARB or combination therapy of ACEI and ARB for a mean follow- up period of 12 months. Aldosterone breakthrough was determined according to the change of plasma aldosterone concentration before and after treatment during 6- month and 12-month ACEI/ARB treatment. Results In 6 months, aldosterone breakthrough occurred in 21 patients, corresponding to 14.58%, while in 12 months, occurred in 39 patients, corresponding to 27.08%. Although the overall urinary protein excretion （UPE） decreased after treatment in both groups （P〈 0.05）, non- breakthrough group had a more remarkable reduction in UPE （P〈O.05）. Univariate Logistic regression demonstrated that risk factors of aldosterone breakthrough included pre-treatment values of UPE （OR=3.643, P=0.073） and eGFR （0R=0.980, P=0.025 ）. Multivariate Logistic model revealed pre-treatment values of eGFR was positively associated with aldosterone breakthrough （OR=0.980, P=0.025）.Conclusions The incidence of the aldosterone breakthrough increases with duration of treatment. The patients with aldosterone breathrough have higher level of UPE, and enhanced decline in eGFR. Pre- treatment value of eGFR is independent risk factor of aldosterone breakthrough.