2017欧洲血液透析病人高血压管理共识及治疗

血液透析病人高血压管理,2018.3人工肾 zwb,透析患者高血压概况,流行病学发病机制诊断与监测干预措施总结,概 况,1.透析的ESRD患者多伴高血压，血压状况控制不佳2.透析前后血压与心血管事件及死亡呈现J型或U型相关曲线3.但家庭血压和动态血压与预后研究发现，高血压患者存在更短的生存时间4.高盐饮食与容量负荷是透析患者高血压主要机制5.一些其他因素也起到重要作用：动脉硬化、RSSA激活、交感兴奋、内皮功能异常、呼吸睡眠暂停、EPO使用等 6.限盐和减轻容量负荷后仍不能控制的高血压采用药物治疗，存在个体化方案,透析患者高血压的患病率,不同研究中对高血压的定义及测定血压的方法不同A cohort study of 10 813 CKD patients （the Kidney Early Evaluation Program） 86.2% (BP130/80mmHg or antihypertensive drugs) Advancing stage of CKD, increasing to 95.5% (or 91% with the use of 140/90 threshold)A study of predialysis CKD patients mean eGFR14.5 ml/min/ 1.73m2 the prevalence of hypertension, 95% Am J Med 2008; 121:332340 Nephron Clin Pract；2012; 120:c147c155.,透析患者高血压的患病率,DOPPS , high and rising over time in all countries 78% in Japan to 96% in Germany（2011）44-h interdialytic ABPM, 82% in a population of 369, the rate of BP control was as low as 38% Am J Nephrol 2011; 34:381390.,透析患者高血压的患病率,起始透析的患者中高血压更常见(大于80%)，容量超负荷引起。持续性高血压通常提示开始透析后容量控制仍然不充分Remove sodium and fluid excess and improve BP control.经过治疗后透析患者比CKD未透析患者更低的高血压发生率Depends on the clinical policies in each dialysis unit Nephrol Dial Transplant 1999; 14:369375,透析患者高血压的发病机制,透析患者高血压的发病机制,Sodium and volume overload 患者出现高血压的主要原因。Not easily identifiable. ESRD patients have the highest sodium-sensitivity of BP钠除了引起渗透压改变外，还以不改变渗透压的形式存在结缔组织及皮肤中，引起巨噬细胞浸润，活化TonEBP蛋白，启动VEGF分泌，通过皮肤淋巴管清除电解质，增加血管NO合成酶的表达。伴随钠及容量的不断增加，可能引起透析间期血压昼夜节律的变化。清除过多钠、降低干体重，可使60%以上的血液透析患者和许多腹膜透析患者的血压恢复正常 J Clin Invest 2013; 123:28032815.,透析患者高血压的发病机制,Arterial stiffness increasea mainly result of disturbed calciumphosphate homeostasisPWV 主动脉脉搏波传导速度（长期改变）Arterial stiffness indexes（interdialytic periods）Sympathetic nervous system activationRAAS activationEndothelial dysfunctionNO生成减少，ADMA生产增加（抑制NO生成，增加室壁厚度）不对称二甲基精氨酸,透析患者高血压的发病机制,Sleep apneahighly prevalent among dialysis patientsvolume overload influences the neck soft tissuesAssociated with nocturnal hypertension(夜间高血压) higher LV wall thicknessHigher risk of developing resistant hypertension（140/90，3种）Erythropoietin-stimulating agents （EPO）Higher EPO doses，higher target Hb levels， higher BP responsecauses of hypertension肾血管性高血压、肿瘤、甲状腺疾病等 J Hypertens 2012; 30:960966.,透析患者高血压的诊断,2004 NKF-KDQI guidelines, hemodialysis patients Predialysis BP is more than 140/90mmHg Postdialysis BP is more than 130/80mmHg,透析中测量方法不规范，白大衣效应、测量过快放气、病人紧张、容量状态变化、超滤、透析参数的改变等主要用于透中血流动力学评估，不能用于高血压的诊断及治疗的评估imprecise estimates of the mean interdialytic BP (透析间期)， relative to 44-h ABPM,透析患者高血压的诊断,peridialytic BP a weaker prognostic relationship with mortality, compared with interdialytic BPwith a standardized protocol ,but poorly to 44-h ABPM values.The rate of errors in the diagnosis of hypertension is unacceptably high一项统评价，与44小时ABPM相比，透析前收缩压的差异为高42mmHg至低25mmHg，透析后收缩压的差异为高33mmHg至低36mmHg Hypertension 2010; 55:762768. Hypertension2016; 67:10931101.,透析患者高血压的诊断,Intradialytic BPThe average of intradialytic BP measurements (cutoff of 140/90mmHg) provided greater sensitivity and specificity in detecting interdialytic hypertensionHome BP exhibits stronger associations with mean 44-h ambulatory BPthe DRIP trial, home BP changes after dry-weight reduction, closely associated with the changes in 44-h ambulatory BP,透析患者高血压的诊断,Intradialytic BP or Home BPHome BP was shown to have high short-term reproducibilityHome BP exhibits stronger associations with target-organ damage A more powerful predictor of future cardiovascular events or mortalitystrong association with cardiovascular outcomes prognostic,透析患者高血压的诊断,ABPMThe gold-standardmethod for diagnosing hypertension？strongly associated with the presence of target-organ damagePredicts allcause and cardiovascular mortality better than peridialytic BPThe advantage of recording nocturnal BP (夜间)Nondipping nocturnal BP is very common associated with LVH and mortality risk,透析患者高血压的诊断阈值,透析患者高血压的诊断,Home BP or ABPM？ABPMuncomfortable and inconveniena high treatment burdennot reimbursed (不报销)Home BPA simpler and more efficient approachABPM确定家庭自测血压读数，最好在透析间期监测44小时。ABPM通常显示血压 随容量增加呈线性升高,更好的监测容量变化。Home BP，尚不明确最佳监测频率。建议每月进行1次家庭血压监测。,透析患者高血压的诊断,Intradialytic elevation or intradialysis hypertension? a matter of debate（透析期间BP）透析后期(大多数液体已被清除)出现反常高血压间歇性出现，且发作频率变动很大发病机制不明，一些证据表明，NO/内皮素-1平衡改变和/或内皮功能紊乱可能具有一定促进作用透析期间高血压与容量过多和透析间期高血压有关尚不明确最佳治疗方案，卡维地洛也可能有效，其可阻断内皮素-1的释放（发作频率从77%降至28%）钠浓度低于患者血清钠水平的透析液，可能降低透析期间的血压,透析患者高血压治疗,血压控制目标尚不明确应进行治疗的血压阈值一项纳入了150例血液透析患者的前瞻性队列研究显示，家庭测量的收缩压值为125-145mmHg时，死亡结局最佳。建议维持透析间期家庭自测血压小于135/85mmHg Clin J Am Soc Nephrol. 2007;2(6):1228.,透析患者高血压治疗,非药物干预措施,透析患者高血压治疗,透析患者高血压治疗,评估容量状态pedal edema was not associated with more objective indices(足部水肿不客观)生物阻抗容积描记法、相对血浆容量(RPV)监测、下腔静脉直径测定以及血浆钠尿肽(ANP和BNP)浓度测定，肺部超声降低目标干体重数日到数周期间减少目标体重（每次透析增加0.5L超滤量，不能耐受，每次增加0.2L）避免透析间期体重增加过多(理想情况为2-3L)限制饮食(每日摄入1.5-2.0g钠)延长透析时间或增加透析频率夜间透析、增加透析次数可有效控制血压（6-7次，夜间睡眠时，总计6-12小时)每日短时血液透析。避免每次短时透析,透析患者高血压治疗,降低透析液的钠浓度一项研究，比较了钠浓度从155mEq/L程序化降至135mEq/L，稳定在140mEq/L的标准透析方案，钠浓度变化的透析后血压降低，降压药使用也减少一项研究，a standard dialysate sodium concentration (138 mEq/l) and average predialysis sodium multiplied by 0.95, a benefit of individualized sodium单一的标准化钠浓度，不一定适合于所有病人,透析患者高血压治疗,降压药物选择,透析患者高血压治疗,一线药物单纯透析未能控制或已控制高血压的患者，倾向把受体阻滞剂作为一线药物受体阻滞剂中阿替洛尔有更多证据受体阻滞剂无效加用二氢吡啶类钙通道阻滞剂，如氨氯地平受体阻滞剂联合钙通道阻滞剂无效加用ACEI或ARB（ACEI可能引发AN69者类过敏反应） Nephrol Dial Transplant. 2014;29(3):672. Epub 2014 Jan 6.,透析患者高血压治疗,难治性高血压（容量控制和初始降压药物无效）原因：同时使用升高血压的药物(如NSAID)、肾血管性高血压、对药物治疗方案不依从以及多囊的囊肿扩大，患者的依从性差如果无法找到可治疗病因，米诺地尔可能有效盐皮质激素受体拮抗剂，常用于具有难治性高血压的非透析患者盐皮质激素受体拮抗剂，可引起高钾血症不能控制的危及生命的高血压，可考虑行双侧肾切除术试验性治疗(包括肾去神经术),总 结,高血压透析患者中常见，尤其开始透析时。容量负荷是主要原因，但交感神经过度兴奋、RAAS激活、动脉硬化也具有一定促进作用采取家庭自测血压的方式来监测血压，以筛查高血压。家庭自测血压的读数与动态血压监测(ABPM)的读数相对应不使用透析前后的血压值来诊断高血压及确定降压治疗，因测定值与ABPM或临床结局无关。建议