高血压肾病的循证降压课件

高血压肾病的循证降压高血压肾病的循证降压从病理生理到ALLHAT与AASK研究的思考高血压肾病的循证降压PrimaryDiagnosisForPatientsWhoStartDialysis

Diabetes50.1%Hypertension27%Glomerulonephritis13%Other10%UnitedStatesRenalDataSystem.Annualdatareport.2000.NoofPatientsProjection95%CI198419861988199019921994199619982000200220042006200820100100200300400500600700R2=99.8%243,524281,355520,240NumberofDialysisPatients(thousands)高血压病是ESRD第二大病因高血压肾病的循证降压ALLHAT和AASK研究病理生理高血压肾病的循证降压高血压肾病的循证降压病理生理HillGS,CurrOpinNephrolHypertens.2008May;17(3):266-70HypertensivenephrosclerosisIschemicFSGSHypertrophicFSGSChronichypertensionNarrowofinterlobular,afferentarterioleReductioninglomerularbloodflow高血压肾病的循证降压RenalbloodflowGFR01002001.51.00.50Flow,l/minArterialbloodpressure,mmHgAutoregulationofRBF&GFRi.e.theresistancesoftheinterlobularartery,afferentarteriole病理生理高血压肾病的循证降压病理生理高血压肾病的循证降压病理生理HillGS,CurrOpinNephrolHypertens.2008May;17(3):266-70HypertensivenephrosclerosisIschemicFSGSHypertrophicFSGSNarrowandstiffeningarterioleReductioninglomerularbloodflowLossofrenalautoregulationLossofrenalfunctionHarveyJM,Lancet1992Dec12;340(8833):1435-6高血压肾病的循证降压

让我们看看大样本临床试验ALLHAT研究和AASK研究病理生理临床试验

IschemicHypertrophic能否找到临床指标来判断那种模式为主呢?高血压肾病的循证降压RahmanMetal.ArchInternMed2005;165:936-46AntihypertensiveandLipid-LoweringtreatmenttopreventHeartAttackTrialALLHAT42,418patientswithhypertensionSBP>140mmHgand/orDBP>90mmHgORTookmedicationforhypertensionandhadatleastoneadditionalriskfactorforCHDAge>55yearsNHLBIfundedtrialEndpoints:Primary–FatalcoronaryheartdiseaseandnonfatalMI高血压肾病的循证降压eGFR(ml/min/1.73m2)RahmanMetal.ArchInternMed2005;165:936-46*p<0.05vs.Chlorthalidone***BaselineeGFR≥90(ml/min/1.73m2)ALLHAT高血压肾病的循证降压eGFR(ml/min/1.73m2)RahmanMetal.ArchInternMed2005;165:936-46*p<0.05vs.Chlorthalidone***BaselineeGFR60-89(ml/min/1.73m2)

TotalΔGFR(mL/min/y)

C-1.54

A-0.55

L-1.471styearΔGFR(mL/min/y)C-2.3A+1.5L-1.9FollowingΔGFR(mL/min/y)C-1.3

A-1.2

L-1.4ALLHAT高血压肾病的循证降压eGFR(ml/min/1.73m2)RahmanMetal.ArchInternMed2005;165:936-46*p<0.05vs.Chlorthalidone***BaselineeGFR<60(ml/min/1.73m2)TotalΔGFR(mL/min/y)

C-0.50

A+0.23

L-0.451styearΔGFR(mL/min/y)C+0.5A+4.3L+1.0FollowingΔGFR(mL/min/y)C-0.8

A-1.1

L-0.9ALLHAT高血压肾病的循证降压对肾脏来说,ALLHAT研究有两点遗憾没有提供尿蛋白的数据没有eGFR<40ml/min的数据(因为入选对象血肌酐<2mg/dl)AASK研究可以弥补这两点遗憾高血压肾病的循证降压EntryCriteriaAfrican-American(selfreport)18-70yroldwithDBP>95mmHgGFR20-65ml/min/1.73m2Non-diabeticBaselineurineprotein/creatinine<2.5PrimaryRenalOutcomeRateofdecline(slope)iniothalomateGFRAfricanAmericanStudyofKidneydiseaseandhypertension

N=1094AASKJAMA.

2001;285:2719-2728.高血压肾病的循证降压eGFR(ml/min/1.73m2)031224360510-5-10BaselineUp/Cr≤0.22ΔGFR(mL/min/y)

Amlodipine+0.20Ramipril-1.02

TotalslopeAmlodipinevsramipril:=3.6,p=0.006

JAMA.

2001;285:2719-2728.MonthsAASK高血压肾病的循证降压eGFR(ml/min/1.73m2)03122436BaselineUp/Cr>0.2205-5-10-15-20ΔGFR(mL/min/y)Amlodipine-5.62

Ramipril-3.60Totalslope

Amlodipinevsramipril:

=-6.06,p=0.006

JAMA.

2001;285:2719-2728.MonthsAASK高血压肾病的循证降压JAMA.

2001;285:2719-2728eGFR(ml/min/1.73m2)031224360510-5-10MeanBaselineGFR≥40ml/minper1.73m2ΔGFR(mL/min/y)

Amlodipine-0.55

Ramipril

-1.53TotalslopeAmlodipinevsramipril:

=-2.91,p=0.003

MonthsAASK高血压肾病的循证降压eGFR(ml/min/1.73m2)0312243605-5-10-15-20JAMA.

2001;285:2719-2728.MonthsMeanBaselineGFR<40ml/minper1.73m2ΔGFR(mL/min/y)

Amlodipine-4.33

Ramipril

-2.73TotalslopeAmlodipinevsramipril:

4.83,p=0.003

AASK高血压肾病的循证降压没有明显蛋白尿(UP/Cr

0.22)和肾功能损害早期（GFR≥40ml/min）高血压肾病明显蛋白尿(UP/Cr>0.22)或肾功能损害晚期（GFR<40ml/min）CCB获益更大些ACEI获益更大些ischemichypertrophic启示高血压肾病的循证降压Upro/cr0.8,Ccr50ml/min.临床实践良性肾小动脉硬化患者Upro/cr0.10,Ccr55ml/min.长效CCB…...ACEI基础的方案……5年后高血压肾病的循证降压

临床实践高血压肾病的循证降压结论高血压肾病的循证降压谢谢！高血压肾病的循证降压△GFR(ml/min/1.73m2)031224360510-5-10BaselineUp/Cr≤0.22ΔGFR(mL/min/y)

Amlodipine+0.20Ramipril-1.02

TotalslopeAmlodipinevsramipril: