Hypertension Management in Patients with Chronic Kidney Disease

Hypertension and chronic kidney disease are closely linked. Patients with chronic kidney disease have hypertension almost universally and uncontrolled hypertension accelerates the decline in kidney function. The pathophysiology of hypertension in chronic kidney disease is complex, but is largely related to reduced nephron mass, sympathetic nervous system overactivation, involvement of the renin-angiotensin-aldosterone system, and generalized endothelial dysfunction. Consensus guidelines for blood pressure targets have adopted a blood pressure <120/80 mm Hg in native chronic kidney disease and <130/80 mm Hg in kidney transplant recipients. Guidelines also strongly advocate for renin-angiotensin-aldosterone system blockade as the first-line therapy.     

Hypertension Treatment for Patients with Advanced Chronic Kidney Disease

Chronic kidney disease is common and frequently complicated with hypertension. As a major modifiable risk factor for cardiovascular disease in this high risk population, treatment of hypertension in chronic kidney disease is of paramount importance. We review the epidemiology and pathogenesis of hypertension in chronic kidney disease and then update the latest study results for treatment including salt restriction, invasive endovascular procedures, and pharmacologic therapy. Recent trials draw into question the efficacy of renal artery stenting or renal denervation for hypertension in chronic kidney disease, as well as renin-angiotensin-aldosterone system blockade as first line therapy of hypertension in end stage renal disease. Positive trial results reemphasize salt restriction and challenge the prevailing prejudice against the use of thiazide-like diuretics in advanced chronic kidney disease. Last, clinical practice guidelines are trending away from recommending tight blood pressure control in chronic kidney disease.     

Rehabilitation Program in Adult Congenital Heart Disease Patients with Pulmonary Hypertension

Introduction. It is commonly believed that physical activity may have a negative impact on pulmonary hypertension patients. The object of this study is to determine the tolerability of a directed exercise program in congenital heart disease patients with pulmonary hypertension. Methods. Eight congenital heart disease patients with pulmonary hypertension were studied and followed up during a 1-year period. Four of them were enrolled in a 3-month rehabilitation program. Results. No significant changes in analytical data, hand and leg strength, or quality of life were seen at the end of the training program in rehabilitation and nonrehabilitation patients. However, patients in the rehabilitation group improved 6 minutes' walk test minimum hemoglobin oxygen saturation and functional class after ending the training program without having adverse events such as progression of symptoms or heart failure. Conclusions. Cardiopulmonary rehabilitation appears to be a safe intervention in patients with congenital heart disease and pulmonary hypertension.     

慢性肾脏病患者高血压发病机制新进展

传统观点将慢性肾脏病的高血压发病机制分为容量依赖型和肾素依赖型两种,但这并未完全阐明肾脏疾病时高血压的发生机制。因为近年来,人们发现在减少血容量和抑制肾素一血管紧张素系统之后,仍不能有效控制血压,从而一些新的机制被提出。本文着重对这些尚未完全公认的发病机制作一综述。     

甲状腺疾病伴发肺动脉高压研究进展

甲状腺疾病伴发肺动脉高压是肺循环高压最新分类中的一种,甲状腺疾病可以通过多种机制引起肺动脉压力增高,并加重其血流动力学状态的恶化。对肺动脉高压患者进行全面及时的甲状腺检查非常重要,治疗甲状腺疾病可以在一定程度上降低肺动脉压力,改善预后。     

Association of Markers of Iron Stores with Outcomes in Patients with Nondialysis-Dependent Chronic Kidney Disease

Background and objectives: Assessments of iron stores by serum iron saturation ratio (ISAT) and ferritin are used to direct anemia therapy in chronic kidney disease (CKD) and are associated with clinical outcomes in patients on dialysis. The association of ISAT and ferritin with outcomes in patients with nondialysis-dependent CKD (NDD-CKD) has not been studied.Design, setting, participants, & measurements: All-cause mortality and progression of CKD [slopes of estimated GFR (eGFR)] were examined in 453 men with NDD-CKD. Mortality and the composite of mortality and ESRD were studied in Cox models. Slopes of eGFR were examined in mixed-effects models.Results: Lower ISAT was associated with higher mortality; adjusted hazard ratio [95% confidence interval (CI)] with ISAT of <12%, 13 to 17%, and >23% versus 18 to 23%; 1.40 (0.99 to 1.98), 1.20 (0.82 to 1.76), and 0.97 (0.67 to 1.41), P = 0.025 for trend. ISAT was also associated with steeper slopes of eGFR (one log-unit higher ISAT associated with a slope of −0.89 ml/min/1.73m² /yr (95% CI: −1.75, −0.02, P = 0.044). Serum ferritin level showed no significant association with outcomes overall, but a trend for higher mortality was observed in patients with a serum ferritin level >250 ng/ml.Conclusions: Higher ISAT is associated with lower mortality and with more progressive CKD. Clinical trials are needed to examine if correction of low iron levels can improve mortality without affecting kidney function in NDD-CKD.Iron is an essential trace element which plays an important role in the catalysis of oxidative reactions and in the transport of soluble gases (1). Assessment of iron stores is done routinely in everyday nephrology practice (2), through measurement of total iron saturation (ISAT; also known as transferrin saturation) and serum ferritin (3).Iron deficiency is common in patients with nondialysis-dependent chronic kidney disease (NDD-CKD) (4,5), but it is unclear to what extent levels of ISAT and ferritin are associated with outcomes in this population. Examining hard endpoints is especially important given the concern that exceeding certain limits of ISAT or ferritin may be deleterious through excess iron deposition and induction of oxidative stress (6–9). We examined the associations of these iron markers with all-cause mortality, the composite of predialysis mortality or ESRD, and the slopes of estimated GFR (eGFR) in 453 men with moderate and advanced NDD-CKD.     

Effects of Pulmonary Hypertension on Exercise Capacity in Patients With Chronic Obstructive Pulmonary Disease

IntroductionThe impact of pulmonary hypertension (PH) on exercise tolerance in chronic obstructive pulmonary disease (COPD) has not been fully elucidated. It is necessary to characterize pulmonary hemodynamics in patients with moderate to severe COPD in order to improve their management. The aim of the study was to determine whether in COPD the presence of PH is associated with reduced exercise tolerance in a cohort of stable COPD patients.MethodsCross-sectional analysis of 174 COPD patients clinically stable: 109 without PH and 65 with PH (COPD-PH). We assessed socio-demographic data, lung function, quality of life, dyspnea, cardiopulmonary exercise testing (CPET), constant workload endurance time (CWET), and six-minute walk test (6MWT). We elaborated a logistic regression model to explore the impact of PH on exercise capacity in COPD patients.ResultsCOPD-PH patients showed lower exercise capacity both at maximal (CPET) (43(20) versus 68(27) Watts and 50(19)% versus 71(18)% predicted peak oxygen consumption (VO₂peak), COPD-PH and COPD, respectively), and at submaximal tests (6MWT) (382(94) versus 486(95) m). In addition, the COPD-PH group had lower endurance time than the non-PH COPD group (265(113) s and 295(164) s, respectively).ConclusionsThe presence of PH is an independent factor that impairs exercise capacity in COPD.     

Association of Hyponatremia and Outcomes in Pulmonary Hypertension

BackgroundHyponatremia is known to be an important marker and prognosticator in left-sided heart failure. However, less is known about the significance of hyponatremia in pulmonary hypertension, particularly in the absence of left ventricular dysfunction.Methods and ResultsWe identified 635 patients with pulmonary hypertension and preserved ejection fraction who were normonatremic (n = 493) or hyponatremic (n = 142). End points were mortality and readmission at 1 year. Overall, 27% of all of the patients died within 1 year. Hyponatremia was significantly associated with an increased rate of 1-year mortality (hazard ratio [HR] 1.82, 95% confidence interval [CI] 1.27–2.61; P = .001) and trended toward an association with the composite of mortality and readmission (HR 1.25, 95% CI 0.97–1.62; P = .08). Additionally, the severity of hyponatremia was directly related to the rate of 1-year mortality (P < .001).ConclusionsHyponatremia is an indicator of poor prognosis in patients with echocardiographic evidence of pulmonary hypertension.     

银杏叶片对慢性肺心病肺动脉高压影响的临床观察

目的 :为探讨银杏叶片对慢性肺心病患者肺动脉高压的影响。方法 :将 42例缓解期肺心病患者分为两组 ,治疗组 2 7例 ,口服银杏叶片 ,每日 3次 ,每次 2片 (80mg) ,对照组 15例 ,口服安慰剂 ,每日 3次 ,每次 2片 ,两组病例分别于治疗前、治疗第 2 0天和第 40天时分别作心脏彩超 1次 ,测三尖瓣区血液返流速度 (Vt)计算出收缩期肺动脉压 (SPAP)。结果 :统计学分析显示治疗组治疗后Vt有非常显著下降 (P <0 .0 1) ,Vt2 、SPAP有显著下降 (P <0 .0 5 ) ;对照组治疗前后各指标无明显变化 ,两组比较 ,银杏叶片与安慰剂治疗效果有显著差异。结论 :本研究表明银杏叶片可显著降低SPAP ,可用于肺心病的防治。     

Nonprogressive Kidney Dysfunction and Outcomes in Older Adults with Chronic Kidney Disease

OBJECTIVES: To determine whether a subgroup of patients with severe but nonprogressive renal dysfunction exist and to characterize this subgroup. DESIGN: Retrospective longitudinal monocentric cohort study. SETTING: Nephrology clinic for chronic kidney disease (CKD). PARTICIPANTS: Between January 1998 and December 2004, 177 consecutive patients aged 80 and older were referred for the first time to nephrology for CKD. MEASUREMENTS: The characteristics of patients with nonprogressive or progressive CKD (estimated glomerular filtration rate (eGFR) decline of < and ≥1 mL/min per 1.73 m² per year, respectively) were observed and analyzed, and their risk of dying or requiring dialysis was determined. After exclusion of subjects requiring immediate dialysis or followed up for less than 6 months, 138 patients remained eligible for analysis. RESULTS: In the study cohort (initial mean eGFR 31.8 mL/min per 1.73 m², median follow‐up 47 months), patients were more likely to require dialysis than to die; 36% of patients had nonprogressive CKD. This characteristic, predicted by low proteinuria, lack of hypertension, and low cardiovascular comorbidity, was the strongest predictor of global survival. In progressors, two independent covariates (eGFR <30 mL/min per 1.73 m² and hemoglobin ≤11 g/dL at inclusion) predicted the risk of requiring dialysis. CONCLUSION: More than one‐third of subjects aged 80 and older referred to a nephrology center had severe but nonprogressive kidney dysfunction. This subgroup had a lower mortality rate than those with progressive kidney dysfunction. Simple covariates (low proteinuria, lack of hypertension, low cardiovascular comorbidity) predicted nonprogression of CKD. Distant nephrology follow‐up of such patients may be sufficient.     

Pulmonary Abnormalities in Patients with Portal Hypertension

Ｔｈｉｓｒｅｖｉｅｗｆｏｃｕｓｅｓｏｎｔｈｅ ｐｕｌｍｏｎａｒｙｖａｓｃｕｌａｒｃｏｍｐｌｉｃａｔｉｏｎｓｏｆｐｏｒｔａｌｈｙｐｅｒｔｅｎｓｉｏｎ .Ｔｈｅｗｉｄｅｓｐｅｃ ｔｒｕｍｏｆｐｕｌｍｏｎａｒｙｖａｓｃｕｌａｒｄｉｓｏｒｄｅｒｓｉｎｌｉｖｅｒｄｉｓｅａｓｅａｎｄｐｏｒｔａｌｈｙｐｅｒｔｅｎｓｉｏｎｒａｎｇｅｓｆｒｏｍｔｈｅｈｅｐａｔｏｐｕｌｍｏｎａｒｙｓｙｎｄｒｏｍｅ (ＨＰＳ)ｃｈａｒａｃｔｅｒｉｚｅｄｂｙｉｎｔｒａｐｕｌｍｏｎａｒｙｖａｓ ｃｕｌａｒｄｉｌａｔａｔｉｏｎｓ,ｔｏｐｕｌｍｏｎａｒｙｈｙｐｅｒｔｅｎｓｉｏｎ (ｐｏｒｔｏｐｕｌ ｍｏｎａｒｙｈｙｐｅｒｔｅｎｓｉｏｎ) ,ｉｎｗｈｉｃｈｐｕｌｍｏｎａｒｙｖａｓｃｕｌａｒｒｅ ｓｉｓｔａｎｃｅｉｓｅｌｅｖａｔｅｄ .Ｔｈｅｅｘａｃｔｐａｔｈｏｐｈｙｓｉｏｌｏｇｉｃａｌｍｅｃｈ ａｎｉｓｍｓｏｆｔｈｅｓｅｐｕｌｍｏｎａｒｙｖａｓｃｕｌａｒｄｉｓｏｒｄｅｒｓａｒｅｕｎ ｋｎｏｗｎ .Ｈｏｗｅｖｅｒ ,ｓｉｎｃｅＨＰＳａｎｄｐｏｒｔｏｐｕｌｍｏｎａｒｙｈｙ ｐｅｒｔｅｎｓｉｏｎｈａｖｅｂｅｅｎｒｅｐｏｒｔｅｄｉｎｐａｔｉｅｎｔｓｅｘｔｒａｈｅｐ...     

吸入一氧化氮对慢性阻塞性肺疾病继发肺动脉高压患者血流动力学的影响及机理

对１８例慢性阻塞性肺疾病继发肺动脉高压患者行右心漂浮导管术,观察吸入４０ｐｐｍ一氧化氮对患者血流动力学、血气、肺内气体交换、高铁血红蛋白的影响及其与血浆环磷酸鸟苷变化的关系。结果发现,吸入一氧化氮２、８、１５ｍｉｎ时,肺血管阻力分别下降了２８．１％、３１．３％及３４．４％,平均肺动脉压也相应降低（Ｐ均〈０．０１）。停止吸入一氧化氮后２ｍｉｎ,肺血管阻力和平均肺动脉压又恢复至吸入前水平,但吸入一氧化     

丹参酮ⅡA磺酸钠对肺心病急性加重期血栓前状态及肺动脉高压的影响

目的 探讨丹参酮ⅡA磺酸钠对慢性肺心病急性加重期血栓前状态及肺动脉高压的影响.方法 将56例慢性肺心病急性加重期患者随机分为两组,治疗组31例,常规组25例,另选同期健康成人26例为健康对照组,常规组予常规抗感染、平喘、扩管利尿、吸氧等常规治疗,治疗组在此基础上给予丹参酮ⅡA磺酸钠40mg/d静滴14d.观察两组患者治疗前、后测定全血黏度、纤维蛋白原、D-二聚体、肺动脉收缩压.结果 肺心病患者全血低切黏度,纤维蛋白原、D-二聚体及肺动脉收缩压与对照组间差异均有显著性意义（P＜0.05）.治疗组患者治疗后全血黏度、纤维蛋白原、D-二聚体、肺动脉收缩压显著降低（P＜0.05）,常规组治疗前、后各指标差别无显著意义（P＞0.05）.结论 丹参酮ⅡA磺酸钠可明显抑制肺心病急性加重期的血栓前状态、降低肺动脉压.