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单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,11/15/2019,#,血液透析病人高血压管理,2018.3,人工肾,zwb,1,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,2,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,3,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.,4,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,.,5,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;14:369375,6,透析患者高血压的发病机制,7,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.,8,透析患者高血压的发病机制,Arterial stiffness increase,a mainly result of disturbed,calciumphosphate,homeostasis,PWV,主动脉脉搏波传导速度（长期改变）,Arterial stiffness indexes,（,interdialytic periods,）,Sympathetic nervous system activation,RAAS activation,Endothelial dysfunction,NO,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,9,透析患者高血压的发病机制,Sleep apnea,highly prevalent among dialysis patients,volume overload influences the neck soft tissues,Associated with nocturnal hypertension(,夜间高血压,)higher LV wall thickness,Higher risk of developing resistant hypertension,（,140/90,，,3,种）,Erythropoietin-stimulating agents,（,EPO,）,Higher EPO doses,，,higher target Hb levels,，,higher BP response,causes of hypertension,肾血管性高血压、肿瘤、甲状腺疾病等,J Hypertens 2012;30:960966.,10,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,11,透析患者高血压的诊断,peridialytic BP,a weaker prognostic relationship with mortality,compared with interdialytic BP,with 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,.,12,透析患者高血压的诊断,Intradialytic BP,The average of intradialytic BP measurements(cutoff of 140/90mmHg)provided greater sensitivity and specificity in detecting interdialytic hypertension,Home BP exhibits stronger associations with mean 44-h ambulatory BP,the DRIP trial,home BP,changes after dry-weight reduction,closely associated with the changes in,44-h ambulatory BP,13,透析患者高血压的诊断,Intradialytic BP or,Home BP,Home BP was shown to have high short-term reproducibility,Home BP exhibits stronger associations with target-organ damage,A more powerful predictor of future cardiovascular events or mortality,strong association with cardiovascular outcomes prognostic,14,透析患者高血压的诊断,ABPM,The gold-standardmethod for diagnosing hypertension,？,strongly associated with the presence of target-organ damage,Predicts allcause and cardiovascular mortality better than peridialytic BP,The advantage of recording nocturnal BP,(,夜间,),Nondipping nocturnal BP is very common,associated with LVH and mortality risk,15,透析患者高血压的诊断,阈值,16,透析患者高血压的诊断,Home BP or ABPM,？,ABPM,uncomfortable and inconvenien,a high treatment burden,not reimbursed,(,不报销,),Home BP,A simpler and more efficient approach,ABPM,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。,17,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,18,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,.,19,透析患者高血压治疗,非药物干预措施,20,透析患者高血压治疗,21,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
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