非糖尿病慢性肾病患者RASI治疗后醛固酮逃逸现象

Clinical observation and analysis of aldosterone escape in patients with non-diabetic nephropathy by RASI-therapy

目的:研究非糖尿病慢性肾病(CKD)患者醛固酮(Ald)逃逸的发生率及影响因素分析。方法:纳入非糖尿病CKD患者104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Ald浓度的变化,确定是否发生Ald逃逸,同时分析影响因素。结果 :肾素-血管紧张素-醛固酮系统抑制剂(RASI)治疗12个月时Ald逃逸的发生率显著高于治疗6个月时(26.92%vs.14.42%,P=0.007)。治疗12个月时,不同CKD分期患者Ald逃逸发生率比较差异有统计学意义(P=0.027),CKD3期患者Ald逃逸发生率最高,CKD1期最低。单用氯沙坦治疗时,治疗12个月的Ald逃逸发生率明显高于治疗6个月(P=0.020)。治疗12个月血浆Ald浓度变化与24 h尿蛋白量、血肌酐(Scr)呈正相关(r=0.431,P=0.003;r=0.336,P=0.009),与估算肾小球滤过率(e GFR)呈负相关(r=-0.275,P=0.006)。24 h尿蛋白基线值、e GFR基线值与治疗12个月Ald逃逸的发生相关(OR=3.671,P=0.028;OR=0.972,P=0.019),其中e GFR基线值是独立预测因素(OR=0.970,P=0.012)。结论 :部分非糖尿病CKD患者在RASI治疗后出现Ald逃逸,发生率随治疗时间延长呈升高趋势。肾功能水平与该现象发生有关,e GFR基线值是发生的独立预测因素。

Objective To investigate the incidence and influencing factors of aldosterone escape in patients with non-diabetic nephropathy by RASI-therapy. Methods A total of 104 patients with non-diabetic nephropathy were treated with ARB or combination therapy of ACEI and ARB in a mean follow-up period of 12 months. Aldosterone escape was determined according to the change of plasma aldosterone concentration before and after treatment during 6-month and 12-month ACEI / ARB treatment, while the influencing factors of aldosterone escape in patients with non-diabetic nephropathy was also analyzed after therapy with RASI.Results In 12 months, the incidence of aldosterone escape was significantly higher than that in 6 months（26.92% vs. 14.42%, P = 0.007）. After 12-month treatment, the difference was statistically significant in incidence of aldosterone escape among different stages of CKD（P = 0.027）. Compared with 6-month incidence of aldosterone escape in the losartan group, 12-month incidence increased evidently（P = 0.020）. The Ald level was positively correlated with urinary protein excretion and the Scr level（r = 0.431, P = 0.003 and r = 0.336,P = 0.009, respectively）, and negetively correlated with levels of the e GFR（r =-0.275, P = 0.006）.Univariate Logistic regression demonstrated that risk factors of aldosterone escape included pre-treatment values of the urinary protein excretion（OR = 3.671, P = 0.028） and the e GFR（OR = 0.972, P = 0.019）. Multivariate Logistic model revealed pre-treatment values of the e GFR was positively associated with aldosterone escape（ OR = 0.970, P = 0.012）. Conclusion The incidence of the aldosterone escape increases along with the time of treatment. Renal function has correlated with aldosterone escape and pre-treatment value of the e GFR is an independent risk factor of aldosterone escape.