精品 CKD患者降压治疗的最新理念

• Overall, 627 patients developed ESRD through 2010 with a median follow-up of 19.3 years
2015MDRD长期随访结果： 无论是否进展至ESRD，强化降压获益更显著
进展为ESRD后，两降压组死亡风险
不考虑ESRD情况，两降压组死亡风险
进展为ESRD后， 强化降压中有142例死亡，常规降压组有182例，强化组显著降低死亡为校正风险28％；
Kidney Int.2015 May;87(5):1055-60.
• 严格控制血压可以降低全因死亡率，这一 作用一直延续到ESRD发生之后
• 严格的血压控制不能延缓肾功能恶化的速 度
A cohort of 21,015 adults age 65–105 years with a moderate or severe reduction in eGFR (,60 ml/min per 1.73 m2
– electrolyte abnormalities, – hypotension, syncope, injurious falls
联合治疗
• polypharmacy also adds to treatment burden • often associated with reduced adherence,
结果
MDRD Study (n = 840) AASK Trial (n = 1094)
REIN-2 Trial (n = 338)
CKD患者的RCT系统综述中没有明 确证据显示降压到125/75-130/80 mm Hg优于 140/90 mm Hg。在这些 研究的2-4年的随访中，没有发现临 床结局的获益。 低质量证据提示：对于蛋白尿 300mg/24hr以上的患者，强化降压 或许有利
Weiss et,al. BP and Mortality in Older CKD PatientsClin J Am Soc Nephrol 10，September, 2015
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循证证据来源
• The evidence on the effects of intensive BP-lowering, namely the <120 mm Hg SBP target, on critical clinical outcomes such as CV events and all-cause mortality is considered to be moderate, due to study limitations, while the effect on kidney failure is more tenuous
– MDRD,AASK
• With the adoption of an SBP target <120 mm Hg for all patients with CKD based on the evidence for CV and survival benefits,
– separate targets for patients with and without albuminuria are no longer required.
累积死亡风险 累积死亡风险
28％
18％
处于风险人数 常规降压 强化降压
ESRD后时间（年）
常规降压
常规降压
处于风险人数 常规降压 强化降压
随访时间（年）
常规降压
常规降压
• 2010年，平均随访19.3年后，整体约627例患者进展为ESRD。本研究探讨，强化降压是否能够使进展为ESRD后患者获益 • 结果显示：整体上，强化降压中有212例死亡，常规降压组有233例，强化组显著降低死亡为校正风险18％；
有条件的患者坚持使用RASI
• Withholding these drugs solely on the basis of the level of kidney function will unnecessarily deprive many patients of the CV benefits that they otherwise would have received, particularly when measures could be undertaken to mitigate the risk of hyperkalemia.
>85 years old) • Diabetes
– Diabete-CKDIV-V
• Patients with very low baseline diastolic BP (DBP) (e.g., <50 mm Hg)
另一项系统回顾发现:对于非糖尿病CKD患者，强化 降压同样没有进一步获益
纳入的研究
• Between 1989 and 1993, CKD patients between 18 and 70 years of age with GFR 13–55 ml/min/1.73m2 were randomized to either strict or usual BP control.
– ACCORD andБайду номын сангаасSPRINT data
• The kidney-protective effects of BP-lowering in CKD The evidence is considered to be low quality due to study limitations
– MDRD and AASK trials
– comes from the IDNT and RENAAL studies.
• For CV outcomes,
– the Micro-HOPE study provides the best evidence.
严密监测和及时停用
• When these drugs are used in patients with eGFR <30 ml/min/1.73 m2, close monitoring of serum potassium is required.
?
＜ 140/90 mmHg
• 2012 KDIGO • 2013 日本CKD实践指南 • 2013 欧洲高血压指南 • 2014 JNC8
CKD高血压患者目标推荐是否会回降？
强化降压的副作用
• there were increased risks for hypokalemia and hyperkalemia
biomarkers • beneficial effect on albuminuria & the adverse
effect on eGFR
关于有／无蛋白尿时不同血压目标
• the KDIGO 2012 BP guideline, recommended more aggressive BP-lowering for patients with albuminuria than those without albuminuria.
– There is no evidence supporting an even lower target (e.g., <110 mm Hg) for patients with severely increased proteinuria.
关于特殊人群
• CKDIV，V • Older age at the upper spectrum of age (e.g.,
– such as G3 to G4, A1 – such as G1/2, A2
ACEI&ARB
• There were no differences between ACEi and ARB for the outcomes of
– all-cause mortality, – CV mortality, MI, – stroke, – HF, – kidney function in the albuminuric and non-
which may be attenuated by the use of single pill combination agents.
关于强化降压时的GFR下降
• intrarenal hemodynamic changes • Urinary excretion of various tubular
albuminuric diabetic sub populations
循证证据来源
• The best evidence for kidney-protective effects of RAASi therapy independent of BP control in patients with diabetic G3 to G4, A3
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SPRINT Study
• 非糖尿病 • 120mmHg&140mmHg • 心血管高危 • 1/3CKD，但排除CKDIV期及以上和尿蛋白>1g • 对延缓肾功能恶化没有差别
＜ 130/80mmHg • 2003 JNC7 • 2004 KDOQI •2007 欧洲高血压指南 •2010 中国高血压防治指南 •2012 加拿大高血压指南
CKD患者降压治疗的最新理念
北京协和医院 李航
CKD患者的血压特点
• 高血压和肾脏病常常互为因果关系，并可 以进一步形成恶性循环
• CKD患者高血压难治，控制率偏低 • 血压控制目标必须个体化
– 降压达标同时保证肾脏灌注 – 降压达标过快和过慢都不好
• 血压控制要兼顾尿蛋白的控制 • 常常需要联合不同种类降压药物