【高血压精品英文课件】hypertension in ckd

HypertensioninCKD MichaelJCasey MDWakeNephrologyAssociates HypertensionStats HTNaffectsapproximately1billionworldwide 500billionindirectcostsContinuous consistentandindependentrelationshipbetweenBPandCadsForthoseage40 70 eachincreasedincrementof20 10mmHginBPdoublestheriskofCVDacrosstheentireBPrangeof115 75to185 115 Only35 ofhypertensivepatientsontreatmentareundercontrol HypertensionasDefinedbyJNCVII 120 80 normal optimal 121 139 80 89 pre hypertension ControversialMoreahealthpolicystatement140 160 90 100 Stage1Hypertension 160 100 Stage2Hypertension EvaluationoftheHypertensivePt AgeandrapidityofHBPonsetAccuratemeasurementofBPMedicationreviewFamilyHistoryH OCVDorkidneydiseaseEtOHandtobaccoSleephistory EvaluationoftheHypertensivePt EvidenceofVolumestatusEdemaHeart lungexamforCHFEndOrganDamageAlbuminuria Proteinuria MACR 24hrurine LVH ECG Echo CKD MeasurementofBloodPressure SeatedpositionwitharmsupportedidealAllowpatienttosettleforseveralminutesPropersizedcuffBladdertoencircle80 100 armBladderwidth40 50 ofarmConfirm2readings5minutesapartinbotharmsforinitialdiagnosisIftakeninwristorlegs thecuffmustbeattheleveloftheheart BPMeasurement HomeBPMonitoring SelfreadingsorcontinuousambulatorymonitoringHelpfuladjuncttoofficereadingsMorereadingsinpatientsusualenvironmentBettercorrelatedwithcardiovascularoutcomesImprovespatientcomplianceHelpsclarifysymptomsDefinesmaskedandwhitecoathypertension HomeBPMonitoring PatientsneedtobetaughtpropermethodsNowristcuffsSemi automatedelectroniccuffsCuffneedstobecheckedagainstofficereadingsFrequencyofmonitoringcanvaryAllcurrentoutcomedata guidelines trailsarefromofficereadings AmbulatoryBPMonitoring AmbulatoryBPMonitoring AmbulatoryBPMonitoring MorereproduciblethanofficemeasurementsHelpfulinearlydiagnosisUnexplainedmicroalbuminuriaorLVHWhiteCoatHypertensionResistantHypertensionNolongtermstudiesyet PrevalenceofHTNinCKD HypertensioninCKD 80 ofpatientswithCKDhaveHBPMoststartwithessentialhypertensionAsGFRdecreasesitismoredependentonsalt waterretentionfromdecreasedGFRCKDpatientsalsohavederangementsintheRenin Angiotensin Aldosteronesystem TreatmentofHypertension Goaldependsondiseasestate 130 80ifDM CKD CVDz 125 75ifCKDwithproteinuriaSBPistheissueintheoldDiastolicHBPisaproblemoftheyoungReachingthetargetismoreimportantthanhowyougetthereMultipleinterventionsarenecessaryinmost HypertensiveEmergencies HypertensionisachronicoutpatientdiseasewithrareacutesideeffectsHeadache MSchanges ICH Papilledema CHF Angina Renalfailurewithhematuria HemorrhageareemergenciesrequirehospitalizationOtherwisetreatasymptomaticsevereHBPoverdays weeksClonidineeffectiveforoutpatientacuteBPloweringHoldESA ProgressionofCKDandBP BP COXSVRBP HRXStrokeVolumeXSVRCO cardiacoutputSVR systemicvascularresistance BPFormula LifestyleModificationFirst Always LowSalt 3gm day DASHdietExerciseTobaccoAlcoholSleepApneaNSAIDSDecongestantsDietPills Renininhibitors RAASAgents ACEInhibitorscaptopril enalapril lisinopril ramipril AngiotensinReceptorBlockerslosartan irbesartan valsartan telmisartan DirectReninInhibitors aliskirenAldosteroneReceptorBlockersspironolactone eplerenoneDrugsofChoiceinCKDNotinpregnancy ACEI ARBinCKD GlomerularPerfusion ACEInhibitors FirstclassdrugforallCKDpatientsShouldbeconsideredinallstagesIftoleratedthenreduceddevelopmentofESRD CKDprogressionBestoutcomedatainproteinuricCKDAngioedemaandcoughHyperkalemiaandworseningrenalfunction AngiotensinReceptorBlockers NextchoiceafterACEIbecauseofcostEqualoutcomedataatthispointNoCoughSameissueswithhyperkalemiaandARFCombowithACEIcomingunderfire DirectReninInhibitors Aliskiren Tekturna isonlydrugFirstnewantihypertensiveclassin15yearsPromisingrenal CHFdatabutnohardoutcomesMaybeusefulforproteinuriareductionincombowithARBGIupsetSameissueofhyperkalemiaandARFaswithallRAASagents AldosteroneBlockers PotassiumsparingdiureticsCanboostefficacyofloopdiureticsImprovessurvivalinCHFpatientsReductioninproteinuria otherRAASagentsGynecomastiawithspironolactoneSameissueofhyperkalemiaandARF Diuretics KeytoHBPmanagementinnon ESRDCKDRAASagentsynergyThiazides hydrochlorothiazide chlorthalidone metolazoneK Sparing amiloride triamterene spironolactone eplerenoneLoops furosemide bumetanide torsemide ThiazideDiuretics JNCfirstchoiceBPmedVeryeffectiveinmultipletrialsOftenavailableincombowithRAASagentLowK increaseBG lipidsatdose 25mgIneffectiveatGFR 50Canboostefficacyofloopdiuretics LoopDiuretics NecessarytomaintainvolumestatusinGFR 50FurosemideisclassicbutshorthalflifesopoorforHBPBumetanideissamebutbetterabsorbedTorsemidehasmuchlongerhalf lifeandismychoicenowthatitisgenericTitratetoincreaseUOPthenincreasefrequencyLowpotassiumismainissue especiallywiththiazides metolazone BetaBlockers SelectiveBetaBlockersAtenolol metoprolol bisoprolol nebivololNon selectiveBetaBlockersPropranololAlpha BetaBlockersLabetolol carvedolol BetaBlockers NextclassinCKDpatientsReducesHR SVandalsoreninReducesincidenceofsuddencardiacdeathandarrhythmiasReducesCVeventsinCHF post MICounter actsreflexincreaseinHR COinducedbyvasodilatorsanddiuretics BetaBlockers Carvedolol labetololarebetterforHBPAtenolol metoprololbetterforCHF HRreductionandarrhythmiaPropranololforascites cirrhosis anxietyBradycardiaandfatiguearemainsideeffects CentralAdrenergicAgents ClonidineispredominantdrugProbablysamebenefitsasbblockersNostudiesandneverwillbeSynergywithbblockersdebatableDrymouth fatigue t i d bradycardiaGoodforacuteHBP prnusePatchavailableMethyldopaforHBPinpregnancy DihydropyridineCalciumChannelBlockers Nifedipine amlodipine felodipineDirectvasodilatorsVeryeffective prob4thdrugofchoiceCancauseperipheraledemaespeciallyinfemalesNoeffectonHR CHFIncreaseGFR proteinuria GlomerularPerfusion Non DihydropyridineCCB s DiltiazemandVerapamilReduceHRandLowerBPArrhythmiacontrolReductioninproteinuriabutnorenaloutcomesEdema bradycardia gingivalhyperplasia CyP450interactions OtherVasodilators Alphablockers doxazosin terazosin prazosinHelpwithBHPOncedailyOrthostatichypertension tachycardia CHFHydralazineImprovedoutcomesinAAwithCHFBIDorTIDLupussyndromeModeratelyeffective Minoxidil MostpotentantihypertensiveagentSeverereboundtachycardiaandedemaNeedbetablockerandloopdiureticHairgrowthPericarditisInexpensive HypertensioninESRD GreatareaofdebateRAASAgentsandBetablockersmayimproveoutcomesinnon RCTsWhatiscorrectmeasurement Pre HDBPPost HDBPHomeBPWhentotake holdBPMeds HypertensioninESRD HypertensioninESRD HypertensioninESRD HypertensioninESRD J shapedcurveofsurvivalvsBPinESRDBettersurvivalwithmoderateHBPOnlycomparedtootherESRD Skewedbyyoungpatients SkewedbycardiomyopathyMostHBPisduetoinadequatevolumecontrolDecreaseinterdialyticweightgainChallengeweightLongerHDtimes daily nocturnal PD TreatmentofHBPinESRD GraduallychallengeweighteachHDNoedemaCrampingLowBPManagementofintradialyticHBPUFprofilingNa modelingLowerdialysatetemperatureCarnitenelevels TreatmentofHBPinESRD Donoth