原发性高血压患者血压水平与肾素-醛固酮系统活性相关性的Meta分析

背景　醛固酮过多是导致心肌肥厚、心力衰竭和肾功能受损的重要危险因素，导致心脏、肾脏等高血压靶器官损害更为严重。除原醛症外，临床发现部分原发性高血压患者的血浆肾素活性及血醛固酮水平升高，但目前关于原发性高血压患者血压水平与血浆肾素活性、醛固酮水平的相关性研究偏少，研究结论也不一致。目的　分析原发性高血压患者血压水平与肾素-醛固酮系统活性的相关性，探讨伴高醛固酮血症的原发性高血压患者可能的病理生理机制，为此类患者的早期治疗、延缓高血压靶器官损害提供理论依据。方法　检索PubMed、EMBase、中国知网、维普网和万方数据知识服务平台，检索时限为建库至2020年1月。2名研究者根据文献纳入和排除标准独立筛选文献、提取资料并使用纽卡斯尔-渥太华质量评估量表（NOS）进行质量评价。采用RevMan 5.2软件进行Meta分析。结果　以中国高血压人群为研究对象，共纳入16篇文献、原发性高血压患者1 885例、健康对照者1 438例。NOS偏倚风险评价结果显示16篇文献评分均在5分以上。Meta分析结果显示：试验组的血浆肾素活性〔MD=0.40，95%CI（0.04，0.76）〕、血浆醛固酮水平〔MD=60.03，95%CI（22.28，97.79）〕高于对照组（P<0.05）。但试验组的卧位肾素活性〔MD=-1.27，95%CI（-1.37，-1.16）〕和立位肾素活性〔MD=-1.67，95%CI（-1.88，-1.46）〕均低于对照组（P<0.05）。试验组卧位醛固酮水平〔MD=0.07，95%CI（0.06，0.09）〕、立位醛固酮水平〔MD=0.22，95%CI（0.05，0.39）〕高于对照组（P<0.05）。结论　（1）原发性高血压患者的血浆肾素活性、醛固酮水平与血压正常者相比是有差异的。无论是卧位采血还是立位采血，原发性高血压患者的血浆肾素水平是低于血压正常者的，而醛固酮水平是高于血压正常者的。（2）在部分原发性高血压患者中，肾素活性与醛固酮水平变化方向不一致，提示原发性高血压患者的高醛固酮血症系非肾素依赖性的不适当醛固酮水平增高。在降压药物的选择中，应包含盐皮质激素受体拮抗剂。

Relationship between Blood Pressure Level and Renin-aldosterone System Activity in Patients with Essential Hypertension:a Meta-analysis

Background Increased aldosterone is an important risk factor for cardiac hypertrophy,heart failure and renal impairment,leading to more serious damage to the target organs of hypertension such as heart and kidney.Except for primary aldosteronism(PA),clinical evidence shows that plasma rennin activity and aldosterone are elevated in some patients with essential hypertension.However,there are few studies on the correlation between blood pressure level and plasma renin activity and aldosterone levels in patients with essential hypertension,and the conclusions are also inconsistent.Objective To investigate the relationship between blood pressure and renin-aldosterone system activity,and the potential pathophysiological mechanism of hyperaldosteronemia in essential hypertension patients,to provide a theoretical basis for early treatment of essential hypertension and delaying the development of related target organ damages.Methods The databases of Pub Med,Embase,CNKI,CQVIP and Wanfang Data Knowledge Service Platform were searched from inception to January 2020 to identify articles about the relationship between blood pressure and renin-aldosterone system activity in patients with essential hypertension.Two researchers independently screened the literature based on the inclusion and exclusion criteria,extracted the data,and evaluated the quality using the Newcastle-Ottawa Scale.Rev Man 5.2 was used to conduct meta-analysis.Results A total of 16 articles with Chinese essential hypertensive individuals(n=1885)compared to healthy controls(n=1438)as the participants were included.All scored above 5 points on the Newcastle-Ottawa Scale.The results of meta-analysis showed that plasma renin activity[MD=0.40,95%CI(0.04,0.76)]in essential hypertensive individuals was significantly higher[MD=60.03,95%CI(22.28,97.79)]than that of controls in general(P<0.05).But the supine and standing values of plasma renin activity[MD=-1.27,95%CI(-1.37,-1.16);MD=-1.67,95%CI(-1.88,-1.46)]were lower in essential hypertensive individuals(P<0.05).Essential hypertensive individuals had higher plasma aldosterone level than the controls[MD=60.03,95%CI(22.28,97.79)]on the whole.They also showed higher supine and standing plasma aldosterone levels[MD=0.07,95%CI(0.06,0.09);MD=0.22,95%CI(0.05,0.39)](P<0.05).Conclusion(1)Plasma renin activity and aldosterone levels in patients with essential hypertension were different from those with normal blood pressure.The supine and standing values of plasma renin activity were decreased,and supine and standing values of plasma aldosterone were elevated in essential hypertensive patients.(2)In some patients with essential hypertension,the changes of plasma renin and aldosterone are inconsistent,suggesting that elevated aldosterone may be not renin-dependent in essential hypertension,and mineralocorticoid receptor antagonists should be chosen for antihypertension.