缺血性肾脏病的治疗进展

Treatment progress of ischemic renal disease

动脉粥样硬化性肾动脉狭窄(ARAS)目前是我国肾动脉狭窄的常见病因,其不仅可引起高血压,最终可导致缺血性肾脏病。20世纪90年代前,外科手术是治疗ARAS的主要方法。但是20世纪90年代后经皮腔内肾动脉成形术及放置支架有类似的血管开通率,而并发症发生率及死亡率较外科手术低,从而成为迅速发展的治疗方式。近年来,随机对照的临床研究显示:介入并未显示出较单纯药物治疗在控制血压方面的优势,但介入治疗可减少降压药物的服用剂量。同样研究还显示:无论是血压、肾功能的保护以及死亡率,单纯药物治疗与药物+介入治疗相比无显著差异。一个对包括804例ARAS基于基线肾小球滤过率、肾动脉狭窄程度及肾脏大小的亚组分析,同样没能发现两组在预后方面的不同。此外,对他汀药物的研究显示:其可能有除降脂以外的肾脏保护作用。最近对ARAS患者进行的非随机研究显示:血管紧张素转换酶抑制剂或血管紧张素受体阻滞剂(ACEI或ARB)对患者肾功能的保护及存活有益,因此应该作为药物治疗的一部分。伴肾功能受损的患者应用ACEI或ARB有发生急性肾损伤的可能,但是较容易监测,只要及时减少药物剂量或停用药物,肾功能是可逆的。

Atherosclerotic renal artery stenosis （ARAS） is the most common cause of renal artery stenosis now, which not only causes hypertension, but also ischemic renal disease. Surgical revascularization is associated with significant perioperative morbidity and mortality and is no longer preferred after the 90 era. Percutaneous transluminal renal angioplasty with stent implantation has become the predominant intervention for ARAS since then. There are several randomized trials comparing medical management with angioplasty or renal artery （RA） stenting. It showed that angioplasty was not superior to medical therapy in blood pressure control, but had a significant drug-saving effect. Two large recent trials showed that RA stenting had no benefit over medical therapy in outcomes of blood pressure, renal function preservation, and mortality. Moreover, in the angioplasty and stenting for renal artery lesions （ASTRAL） trial that included 804 patients, a subgroup analysis was done based on baseline glomerular filtration rate （GFR）, degree of stenosis, and renal size, and no difference in outcome was found between the groups. Studies showed that statins had protective effects on kidney beyond lowering lipidemia. Recent nonrandomized trials in ARAS showed that renin angiotensin aldosterone system （RAAS） blockade offers significant benefit in terms of renal function preservation, as well as survival. Agents that block the RAAS improve outcomes and should be a part of the medical regimen in ARAS. Concern of acute kidney injury in ARAS with impaired GFR has been a barrier to the use of these agents, but it can be easily detected early and reversed by discontinuing or adjusting the dose of the drug.