目的:比较钠-葡萄糖协同转运蛋白-2(SGLT2)抑制剂的疗效,非甾体盐皮质激素受体拮抗剂(MRA),选择性醛固酮拮抗剂和非选择性醛固酮拮抗剂,在肾素-血管紧张素-醛固酮系统(RAAS)阻断之上,在减少肾脏特异性复合事件方面,心血管结果,以及2型糖尿病(T2D)和慢性肾脏病(CKD)参与者特别感兴趣的其他事件。
方法:PubMed,搜索了EMBASE和CENTRAL截至2022年1月20日发表的研究。纳入T2D和CKD参与者的随机临床试验,其中SGLT2抑制剂,非甾体磁共振成像,选择性醛固酮拮抗剂和非选择性醛固酮拮抗剂相互比较,或安慰剂或不治疗。使用贝叶斯方法进行网络荟萃分析。主要结果是肾脏特异性复合事件。次要结果包括心血管原因死亡,非致死性心肌梗死,非致命性中风,心力衰竭住院治疗,和全因死亡率。我们还检查了感兴趣的血压和安全结果,包括急性肾损伤,高钾血症,低钠血症,和量减少事件。所有研究均根据PROSPERO数据库(CRD42022307113)中注册的方案进行。
结果:这项对17项随机分组的试验进行的荟萃分析发现,SGLT2抑制剂(比值比[OR]0.62,95%置信区间[CI]0.52至0.73)和非甾体类MRA(OR0.76,95%CI0.66至0.88)与肾脏特异性复合事件明显低于对照组。非甾体MRA(OR0.78,95%CI0.66至0.92)和SGLT2抑制剂(OR0.57,95%CI0.45至0.72)与对照组相比,心力衰竭住院率降低幅度更大。与非甾体MRA相比,SGLT2抑制剂与心力衰竭事件的住院风险较低相关(OR0.73,95%CI0.55-0.97)。与对照组相比,SGLT2抑制剂可降低心血管死亡(OR0.80,95%CI0.65至0.98)和全因死亡率(OR0.79,95%CI0.66至0.93)。与对照组相比,非甾体MRA(加权平均差[WMD]-10.96,95%CI-20.49至-1.46)和SGLT2抑制剂(WMD-3.50,95%CI-6.01至-1.013)均与较低的收缩压有关,非甾体MRA(OR2.27,95%CI2.02~2.56)和非选择性醛固酮拮抗剂(OR3.22,95%CI1.43~7.66)与高钾血症风险增加相关,非甾体MRA与低钠血症风险增加相关(OR16.56,95%CI2.78~455.19),SGLT2抑制剂与容量减少事件的风险增加相关(OR1.28,95%CI1.06~1.56).SGLT2抑制剂在我们的主要和次要结局中排名最佳。对证据的信心通常很高或中等。
结论:在此网络荟萃分析中,SGLT2抑制剂或非甾体MRA的使用,再加上RAAS封锁,与安慰剂或未治疗相比,T2D和CKD患者的肾脏特异性复合事件和心力衰竭事件住院率降低相关.与非甾体MRA相比,SGLT2抑制剂与心力衰竭事件住院风险较低相关。与安慰剂或不治疗相比,使用SGLT2抑制剂与较低的死亡率相关。
OBJECTIVE: To compare the efficacy of sodium-glucose cotransporter-2 (SGLT2) inhibitors, nonsteroidal mineralocorticoid receptor antagonists (MRAs), selective aldosterone antagonists and nonselective aldosterone antagonists, on top of renin-angiotensin-aldosterone system (RAAS) blockade, in reducing kidney-specific composite events, cardiovascular outcomes, and other events of special interest in participants with type 2 diabetes (T2D) and chronic kidney disease (CKD).
METHODS: PubMed, EMBASE and CENTRAL were searched for studies published up to January 20, 2022. Randomized clinical trials enrolling participants with T2D and CKD were included, in which SGLT2 inhibitors, nonsteroidal MRAs, selective aldosterone antagonists and nonselective aldosterone antagonists were compared with either each other, or with placebo or no treatment. A network meta-analysis using a Bayesian approach was performed. The primary outcome was a kidney-specific composite event. Secondary outcomes included death from cardiovascular causes, nonfatal myocardial infarction, nonfatal stroke, hospitalization for heart failure, and all-cause mortality. We also examined blood pressure and safety outcomes of interest, including acute kidney injury, hyperkalaemia, hyponatraemia, and volume reduction events. All research was conducted according to a protocol registered in the PROSPERO database (CRD42022307113).
RESULTS: This meta-analysis of 17 trials randomizing 22 981 participants found SGLT2 inhibitors (odds ratio [OR] 0.62, 95% confidence interval [CI] 0.52 to 0.73) and nonsteroidal MRAs (OR 0.76, 95% CI 0.66 to 0.88) were associated with significantly lower kidney-specific composite events than the control groups. Nonsteroidal MRAs (OR 0.78, 95% CI 0.66 to 0.92) and SGLT2 inhibitors (OR 0.57, 95% CI 0.45 to 0.72) were associated with greater reductions in hospitalization for heart failure than the control groups. SGLT2 inhibitors were associated with a lower risk of hospitalization for heart failure events compared with nonsteroidal MRAs (OR 0.73, 95% CI 0.55-0.97). SGLT2 inhibitors were associated with a reduction in cardiovascular death (OR 0.80, 95% CI 0.65 to 0.98) and all-cause mortality (OR 0.79, 95% CI 0.66 to 0.93) compared with the control groups. When compared to the control groups, both nonsteroidal MRAs (weighted mean difference [WMD] -10.96, 95% CI -20.49 to -1.46) and SGLT2 inhibitors (WMD -3.50, 95% CI -6.01 to -1.013) were linked with lower systolic blood pressure, nonsteroidal MRAs (OR 2.27, 95% CI 2.02 to 2.56) and nonselective aldosterone antagonists (OR 3.22, 95% CI 1.43 to 7.66) were associated with an increased risk of hyperkalaemia, nonsteroidal MRAs were linked with an increased risk of hyponatraemia (OR 16.56, 95% CI 2.78 to 455.19), and SGLT2 inhibitors were associated with an increased risk of volume reduction events (OR 1.28, 95% CI 1.06 to 1.56). SGLT2 inhibitors were ranked the best for our primary and secondary outcomes. Confidence in the evidence was often high or moderate.
CONCLUSIONS: In this network meta-analysis, the use of SGLT2 inhibitors or nonsteroidal MRAs, combined with RAAS blockade, was associated with a reduction in kidney-specific composite events and hospitalization for heart failure events in patients with T2D and CKD compared to placebo or no treatment. SGLT2 inhibitors were associated with a lower risk of hospitalization for heart failure events compared with nonsteroidal MRAs. Use of SGLT2 inhibitors was associated with lower mortality than placebo or no treatment.