Effect of reducing dry body weight and decreasing dialysate sodium concentration on blood pressure control in maintenance hemodialysis patients

目的 探索基于不同病因的个体化治疗模式对改善血液透析(HD)患者高血压控制率的影响.方法 选取我院部分稳定维持性HD患者进行家庭血压(Home-BP)监测,以家庭血压的收缩压(Home-SBP)≥150 mmHg为未控制的高血压的诊断标准,对入组高血压患者进行干预研究.行生物电阻抗检测,血清钠测定,药物使用情况调查,了解水、钠负荷及药物应用合理性情况,有针对性地分别进行降低干体重、低钠透析和合理使用降压药物的干预措施.随访2个月,观察患者高血压控制情况.结果 105例稳定维持性HD患者接受了Home-BP监测,其中未控制的高血压患者60例(57.1％).其中30例患者容量超负荷,针对性地降低干体重后,Home-SBP下降12.0 mmHg (P＜0.001),家庭血压的舒张压(Home-DBP)下降5.0 mmHg(P=0.002),降压药用量显著减少(P=0.030).12例透析前血钠低于标准透析液钠浓度(138 mmol/L)的患者使用低钠透析(136 mmol/L)后,Home-SBP下降14.0 mmHg (P=0.003),Home-DBP下降8.1 mmHg (P=0.014),降压药用量无明显变化(P=0.390).余18例患者通过增加肾素-血管紧张素抑制剂和抗交感治疗,Home-SBP下降11.6 mmHg (P＜ 0.001),Home-DBP下降4.2 mmHg (P=0.021).通过上述治疗,患者未控制的高血压比例从57.1％(60例)降至31.4％(33例)(P＜ 0.001).结论 对HD高血压患者进行有针对性的、个体化的干预治疗措施,能够有效地改善HD高血压患者血压状况.     

家庭血压监测联合个体化透析方案在透析高血压患者的临床应用

目的:探讨家庭血压监测联合个体化透析模式在维持性血液透析高血压患者治疗中的临床效果,为此类患者的临床治疗提供依据。方法:选择2015年6-12月在本院确诊为终末期肾病合并高血压,透析龄≥3个月且继续能在本院维持透析治疗1年以上的病情稳定的患者60例作为研究对象,对比分析60例患者使用该方案前家庭血压及透析过程血压的变化情况,并根据上述血压情况对患者进行个体化治疗,观察治疗后患者血压的变化。结果:通过家庭血压监控和个体化透析模式治疗后,患者干预前后家庭血压变化和睡前加药情况比较,差异均有统计学意义(P0.05)。结论:在充分了解和掌握患者的血压变化情况下,采用可调钠联合超滤模式或者联合较高的透析液温度治疗透析高血压患者,疗效明显,适合在基层医院推广和借鉴。     

个体化治疗模式对高血压维持性血液透析患者居家血压变异度的影响

目的:探究高血压维持性血液透析患者居家血压变异度的情况,并对个体化治疗后的变化情况进行分析。方法:选取96例高血压维持性血液透析患者进行居家血压监测,了解高血压维持性血液透析患者居家血压变异的变化情况,观察并记录患者居家血压变异系数,对未控制的高血压患者进行改善容量负荷、应用低钠透析液以及调整降压药等措施,之后观察患者血压以及血压变异情况。结果:96例高血压维持性血液透析患者中有55例未控制高血压,实施个体化治疗模式之后,居家血压明显降低,居家收缩压变异系数降低。其中25例为容量超负荷患者,降低干体质量(DBW)后,居家收缩压和居家舒张压明显降低(P<0.05);18例血钠浓度较高的患者采用低钠透析液之后,居家血压下降,居家血压变异系数无统计学差异(P>0.05);其余12例容量负荷正常,未使用低钠透析液的患者通过增加使用ACEI、ARB降压药,患者居家血压下降,血压变异度减小,但是差异无统计学意义(P>0.05)。结论:对高血压维持性血液透析患者的各类病因进行治疗,能够有效的改善患者居家血压以及血压变异情况。     

基因重组促红细胞生成素对血透患者一氧化氮、内皮素影响的研究

目的探讨基因重组促红细胞生成素(rHuEpo)对维持性血透患者血管活性物质一氧化氮(NO)、内皮素-1(ET-1)的影响.方法将长期规律性血透尿毒症患者80例分为血液透析应用rHuEpo者(HDepo组n=43例),血液透析不应用rHuEpo者(HD组n=37例),根据血压情况两组再分为HDepo高血压亚组(HDepo-1组,n=23)、HDepo血压正常亚组(HDepo-2组,n=20)和HD高血压亚组(HD-1组,n=19)、HD血压正常亚组(HD-2组,n=18).另选尿毒症未透析患者20例(NHD组)、原发性高血压患者20例、健康对照组34例(CON组).HDepo组患者均接受rHuEpo治疗3个月以上,用比色法测定血NO水平、用放射免疫法测定血ET-1水平.结果尿毒症未透析患者血清NO、ET-1水平明显高于正常对照组,P＜0.001;尿毒症透析患者血清NO、ET-1浓度较正常对照组高,P＜0.001,但经透析治疗的尿毒症患者与尿毒症未透析者比较,血清NO水平较未透析者低、血清ET-1水平较未透析者高,P＜0.05;HDepo组经rHuEpo治疗3月后,血NO浓度降低,血ET-1浓度增高,与用药前及对照组比较,P＜0.05.且用rHuEpo治疗后,HDepo组收缩压、舒张压、平均动脉压均较HD组高,P＜0.001,血压增高与血NO浓度的降低、血ET-1浓度增高有相关性.结论rHuEpo可使尿毒症透析患者血NO浓度降低、血ET-1浓度增高,rHuEpo致高血压与血NO浓度降低、血ET-1浓度增高有一定的关系.     

维持性血液透析患者透析中高血压控制临床相关因素分析

【目的】探讨维持性血液透析患者透析中高血压的发生情况和临床措施。【方法】回顾性分析2010年1月-2012年5月在武警某总队医院血液透析中心行维持性血液透析患者发生透析中高血压（intradialytic hypertension,IDH）的临床资料,观察通过改善容量负荷、调整降压药和改变透析液钙离子浓度等个体化治疗措施对IDH患者透析前后及透析中血压变化的影响。【结果】145例MHD患者中有25例（17.2%）发生IDH,其中19例通过加强超滤脱水后,透析前收缩压、透析3 h平均动脉压及透析后的收缩压、舒张压、平均动脉压均较治疗前显著下降（P〈0.05）,IDH的发生率显著减低（P〈0.01）。2例患者出现透析后高钙血症,改用钙离子浓度为1.25 mmol/L的透析液透析后,未再出现透析中高血压。4例患者通过透析前、透析中分别加用钙离子拮抗剂、卡托普利后,降低了透析前后血压。【结论】容量超负荷可能是透析中高血压的重要原因之一,通过增加超滤、控制干体质量,调整透析液钙离子浓度和降压药有助控制IDH的发生。     

血液透析患者高血压的原因及护理措施

临床资料 本组男30例，女12例；年龄18～42岁，平均50．3岁。原发疾病：慢性肾炎29例，糖尿病肾病7例，高血压肾病5例，痛风性肾病1例。11例透析间期体重增加超过干体重的10％，给予3种以上降压药治疗，其中3例患者透析前收缩压仍高达180～220mmHg（1mmHg=0．133kPa），舒张压高达100～120mmHg；5例新进入高血压在维持性血液透析（MHD）的患者，透析时脱水未达到干体重水平，需要2种以上降压药控制血压；8例每周透析次数为2次，透析间期血压高，透析过程出现透析相关性低血压，血压控制欠佳；其余患者未找到诱发或加重高血压的原因。     

维持性血液透析患者高血压的临床分析

目的分析维持性血液透析患者高血压相关因素及防治方法。方法回顾总结50例维持性血液透析患者年龄、透前透后以及透析间期血压变化情况及透析方法和降血压药物对维持血透期间血压变化的影响。结果随着透析充分性的提高和降压药的使用,高血压有好转趋势,透析间期体重增加明显的患者高血压较严重,且难以控制,加强透析后可控制血压;部分病例充分超滤脱水并不能完全控制高血压,须合理使用降压药,而老年人随超水后血压下降明显。结论水钠潴留是导致高血压最主要因素;需合理调整透析方案、合理应用降血压药物才能有效控制高血压;而正确调节老年人透析参数,高血压可得到控制,并减少低血压的发生。     

可调钠透析对维持性血液透析高血压病人血压影响

目的 探讨可调钠透析对维持性血液透析高血压病人血压的影响.方法 将60例维持性血液透析的高血压病人随机分为常规透析组(A组)和可调钠透析组(B组),每组30例,分别给予标准钠透析和可调钠透析3个月,观察两组病人血压、心率及血清钠浓度的变化.结果 B组病人透析后血压显著改善(t=2.11、2.43,P<0.05);而A组病人透析后血压与透析前比较,差异无统计学意义(P>0.05).两组病人心率和血清钠离子浓度差异无显著性(P>0.05).结论 可调钠透析具有降低维持性血液透析高血压病人血压的作用.     

维持性血液透析患者血浆容量与血压关系的研究

目的探讨维持性血液透析患者透析过程中血浆容量变化与血压的关系。方法 36例维持性血液透析患者根据透析前血压水平分为正常血压组(n=16)和高血压组(n=20)。记录透析前后患者的血压和体质量,检测血清总蛋白水平并计算血浆容量变化值(△PV)。所有数据采用SPSS 13.0软件进行统计学分析。结果在正常血压组,透析前后收缩压分别为(123.3±19.9)mmHg(1 mmHg=0.133 kPa)和(122.3±27.0)mmHg,舒张压分别为(69.6±9.2)mmHg和(70.9±17.0)mmHg,透析前后收缩压和舒张压比较差异均无统计学意义(P>0.05);透析过程中,体质量变化值为(2.7±1.4)kg,△PV为(14.7±10.8)%。在高血压组,透析前后收缩压分别为(162.6±16.2)mmHg和(148.2±31.1)mmHg,透析前后舒张压分别为(86.6±9.6)mmHg和(82.1±14.4)mmHg,透析后收缩压较透析前显著下降(P<0.05),而透析前后舒张压比较差异无统计学意义(P>0.05);透析过程中,体质量变化值为(3.2±1.3)kg,△PV为(20.4±14.4)%。相关...     

透析患者高血压

心血管疾病是维持性血液透析患者的主要死亡原因 ,高血压是导致心血管疾病发生的重要因素。文献报告血液透析患者高血压发生率为 5 0 %～ 85 % ,腹膜透析患者高血压发生率为30 %左右。为了了解血液透析患者高血压发生及控制情况。我院对 1 1 4例维持性血液透析病例稳定透析时透析前后血压指数进行回顾性计算分析。结果 :平均血压指数为 3.7± 2 .2 ,不服用降压药而血压正常者 1 7例 (1 4.9% ) ,其余97例 (85 .1 % )存在不同程度的高血压 ,经服用降压药治疗 ,1 0例 (8.8% )血压控制正常 ,其余87例 (76 .3% )血压仍高。高血压患者中 ,5 5例(5 …     

The association between haemospermia and severe hypertension

The association between haemospermia and hypertension was examined in a case-control study comparing 5 hypertensive patients with haemospermia to 20 age-matched hypertensive men. Patients with haemospermia had much higher blood pressures than hypertensive controls (200/131 mmHg vs 147/90 mmHg; P less than 0.0005/P less than 0.0001), higher left ventricular voltage on ECG (P less than 0.02), and higher concentrations of serum creatinine, proteinuria and renovascular disease (all P = 0.06 vs controls). Haemospermia is associated with severe uncontrolled hypertension. It is not, however, associated with hypertension per se, as the prevalence of hypertension in published series of patients with haemospermia is no higher than that expected in the general population. Men presenting with haemospermia should have their blood pressure measured carefully as they may require antihypertensive treatment urgently.     

Prevalence, awareness, treatment, and control of hypertension in the non-dialysis chronic kidney disease patients

Background Data on the epidemiology of hypertension in Chinese non-dialysis chronic kidney disease (CKD) patients are limited. The aim of the present study was to investigate the prevalence, awareness, treatment, and control of hypertension in the non-dialysis CKD patients through a nationwide, multicenter study in China.

Methods The survey was performed in 61 tertiary hospitals in 31 provinces, municipalities, and autonomous regions in China (except Hong Kong, Macao, and Taiwan). Trained physicians collected demographic and clinical data and measured blood pressure (BP) using a standardized protocol. Hypertension was defned as systolic BP ≥140 mmHg and/or diastolic BP ≥90 mmHg, and/or use of antihypertensive medications. BP <140/90 mmHg and <130/80 mmHg were used as the 2 thresholds of hypertension control. In multivariate logistic regression with adjustment for sex and age, we analyzed the association between CKD stages and uncontrolled hypertension in non-dialysis CKD patients.

Results The analysis included 8927 non-dialysis CKD patients. The prevalence, awareness, and treatment of hypertension in non-dialysis CKD patients were 67.3%, 85.8%, and 81.0%, respectively. Of hypertensive CKD patients, 33.1% and 14.1% had controlled BP to <140/90 mmHg and <130/80 mmHg, respectively. With successive CKD stages, the prevalence of hypertension in non-dialysis CKD patients increased, but the control of hypertension decreased (P<0.001). When the threshold of BP <130/80 mmHg was considered, the risk of uncontrolled hypertension in CKD 2, 3a, 3b, 4, and 5 stages increased 1.3, 1.4, 1.4, 2.5, and 4.0 times compared with CKD 1 stage, respectively (P<0.05). Using the threshold of <140/90 mmHg, the risk of uncontrolled hypertension increased in advanced stages (P<0.05).

Conclusions The prevalence of hypertension Chinese non-dialysis CKD patients was high, and the hypertension control was suboptimal. With successive CKD stages, the risk of uncontrolled hypertension increased.

     

Successful Treatment of Hypertension in Anuric Hemodialysis Patients with a Direct Renin Inhibitor,Aliskiren

Objective: A direct renin-inhibitor (DRI), aliskiren, was administered to anuric patients to investigate whether it can be a new optional therapy against hypertension in hemodialysis (HD) patients.Patients: The patients that received aliskiren comprised 8 males and 2 females with a mean ± SD age of 63 ± 8 years (43-72 years). They were exposed to dialysis therapy for 118 ± 73 months (8-251 months), with diabetes mellitus in 4 cases, chronic glomerulonephritis in 4 cases, and other diagnoses in 2 cases.Methods: After the plasma renin activity (PRA) and plasma aldosterone concentration (PAC) were measured before an HD session, aliskiren, 150 mg as an initial dose, was administered to the patients. PRA and PAC were also examined a week after initiating aliskiren. The blood pressure (BP) levels at the start of each HD session for a period of 2 weeks (6 HD sessions) were compared between before and after administration of aliskiren. The change of doses in other antihypertensive agents was also counted.Results: The averaged reduction of mean blood pressure was 4 ± 5 mmHg, and doses of antihypertensives other than aliskiren were reduced in 4 patients. Of the examined parameters, only the reduction rate of PRA x PAC seemed correlated with the BP lowering effect of aliskiren, which was calculated as the sum of the mean BP reduction in mmHg and drug reduction with 1 tablet (capsule)/day considered to be 10 mmHg.Conclusion: A DRI, aliskiren, was effective even in anuric dialysis patients, and monitoring of PRA and PAC was valuable for selecting cases responsive to aliskiren.     

不同价格降压药物对高血压患者血压达标的影响

目的了解高血压患者不同价格降压药物使用情况及其对血压达标的影响。方法调查高血压患者2100例,年龄28～80岁,平均年龄（62．5±12．1）岁。调查的项目包括：文化程度、用药前后血压、病史、所用药物的名称及每日剂量等。结果自费患者中：①不同文化程度患者之间不同价格药物的使用有明显差异（P〈0．01）,大多数低学历患者使用低价格药物,许多高学历患者也使用低价格药物;②不同病史的患者用药也有明显差异（P〈0．05）,随着病史的延长,高价格药物的使用逐渐增多;③高价格药物单用或与其他价格药物联合使用,治疗达标率都较高。结论文化程度的高低及病史的长短可以影响自费高血压患者对降压药物的选择,从而影响对血压的控制。     

三种透析模式预防血液透析低血压的临床效果比较

目的探讨预防血液透析中低血压的最佳透析模式。方法采用单盲法交叉设计对6例维持性血液透析(HD)中易发生低血压的患者分别采取三种透析模式进行实验研究。结果超滤(UF)曲线HD、钠梯度HD、低温HD这三种透析模式对透析中低血压均有不同程度的预防作用,但这三种透析模式之间两两比较的结果差别均无统计学意义。结论预防透析中低血压首选钠梯度HD,其次是低温HD,最后是UF曲线HD。     

Effect of trial therapy on subsequent therapy. A review of patients with hypertension who have completed a pharmacological intervention study

After a clinical trial was completed in which two commonly used antihypertensive agents (prazosin and propranolol) were compared, 20 previously untreated men with moderate, asymptomatic, essential hypertension returned to the care of their general practitioners. Twelve months later 17 patients who were still attending the same doctor demonstrated improved blood pressure control with a decrease in their lying diastolic blood pressure from 96 +/- 2 mmHg to 91 +/- 2 mmHg (P less than 0.01). Only two of the 17 patients had not by then achieved satisfactory control. Eleven patients (65%) were still taking at least one of the trial medications; clinicians seemed to prefer prazosin (10 patients). Only one of seven patients was still taking propranolol although five patients had begun treatment with other beta-blocking agents. One patient had ceased drug treatment. This survey indicates that many general practitioners are able to maintain or even improve blood pressure control in patients whose blood pressure has been stabilized initially. However, the reasons for the medication preference were unclear and studies of the clinical behaviour that influences a general practitioner's choice of medication are required.     

Hypertension control improved through patient education. Chinese PEP Investigators

OBJECTIVE To evaluate the effects of patient education for hypertension on hypertension control.

METHODS Of 169 eligible patients (systolic blood pressure > or = 160 mmHg and/or diastolic blood pressure > or = 95 mmHg), 60 were assigned to educational group (group E, antihypertensive drug treatment with an addition of patient education) and 109 to routine group (group R, antihypertensive drug treatment alone). The average follow-up approximated to 3 years.

RESULTS The blood pressure was reduced from at baseline and sustained in the three-year follow-up by 20/13 mmHg in group E and by 22/13 mmHg in group R. For this similar blood pressure reduction, about 10 mg less of metoprolol and 6 mg less of nitrendipine were used in group E than in group R. The percentage of the patients in whom goal blood pressure (under 160/90 mmHg) was achieved during follow-up was higher and progressively increased in group E (1st year: 65%, 2nd year: 72%) in comparison with in group R (1st year: 45%; 2nd year: 55%). Body weight was significantly reduced by 1.36 and 1.81 kg from at baseline to at the 1st and 2nd year repeated measurements in group E. The significant reduction from at baseline to at the 2nd year was significantly different from that in group R (P = 0.02). For 24-hour urinary sodium excretion, it was decreased in the group E, whereas it was increased in the group R. The cumulative rates of hypertension-related complications were 4.43% in group E and 7.02% in group R (absolute difference = 2.59%, P = 0.48). The rate of missed appointments was somewhat higher in group R (10%) than in group E (7%) during the first year but lower in the 2nd and 3rd year (R vs E: 10% vs 2% in the 2nd year; 8% vs 2% in the 3rd year). Four patients lost to follow-up in group R (6.87%) and 1 patient in group E (1.74%, P = 0.08).

CONCLUSIONS The findings of this study suggest that patient education is of some benefits to the hypertension control.

     

Hypertension control improved through patient education

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原发性高血压患者血清Fractalkine 水平与血管内皮功能损伤的相关性研究

目的 研究原发性高血压患者Fractalkine（FKN）与血管内皮功能的相关性。方法 纳入50 例原发性高血压患者作为高血压组,50 例健康体检者为对照组。使用酶联免疫吸附法（ELISA）测定血清FKN水平,使用高效液相色谱法测定血浆非对称性二甲基精氨酸（ADMA）水平,硝酸还原酶法测定血清一氧化氮NO 水平。使用高分辨超声检测肱动脉血流介导的内皮依赖性血管舒张功能（FMD）及非内皮依赖性舒张功能（NMD）。38 例原发性高血压患者（剔除12 例）接受3 个月的规范降压治疗。比较治疗前后收缩压、FKN、ADMA、NO、FMD 的变化水平,进一步分析FKN 治疗前后变化量绝对值与收缩压、ADMA、NO、FMD 变化量绝对值的相关性。结果 与对照组比较,高血压组的血清FKN、血浆ADMA 水平升高（P <0.05）,FMD、血清NO 水平降低（P <0.05）。FKN 与ADMA、收缩压、舒张压呈正相关（r =0.785、0.730 和0.785,均P =0.000）,与NO、FMD 呈负相关（r =-0.800 和-0.783,均P =0.000）。经过3 个月的降压治疗,发现收缩压、舒张压、FKN、ADMA 比治疗前降低,NO、FMD 比治疗前升高。其中FKN 治疗变化绝对值（△ FKN）与△收缩压、△舒张压、△ FMD、△ ADMA、△ NO 呈正相关（r =0.720、0.405、0.707、0.687和0.726,P =0.000、0.012、0.001、0.032 和0.001）。结论 原发性高血压患者血清FKN 水平的升高与血管内皮功能的损伤可能有关。降压治疗可改善原发性高血压患者的内皮功能,降低血清中的FKN 水平。     

降压药物相关基因多态性在某院高血压患者中的应用研究

目的 分析来我院就诊高血压患者中降压药物相关基因型的频率分布,为高血压患者个体化治疗提供参考和临床依据。方法 收集2021年6月—2022年4月在中国人民解放军总医院海南医院就诊的高血压患者,共72例。采用PCR-熔解曲线法检测CYP2D6^*10（c.100 C>T）、CYP2C9^*3 （c.1075 A>C）、ADRB1（c.1165 G>C）、AGTR1（c.1166 A>C）、ACE（I/D）、 NPPA（T2238C）和 CYP3A5^*3（A6986G）,并分析不同基因型与生化指标的关系。结果 对72例患者各位点基因及基因型频率进行统计,7个位点基因频率均符合Hardy-Weinberg平衡。ADRB1基因型存在性别差异（χ²=5.878, P<0.05）。AGTR1位点不同基因型的患者之间三酰甘油[AA:1.4（1.0, 2.0） mmol/L;AC：2.2（1.5, 2.5）mmol/L; P=0.038]、总胆固醇[AA:4.0（3.1, 4.9） mmol/L;AC：4.8（4.0, 5.3） mmol/L; P=0.040]、低密度脂蛋白胆固醇[AA:2.4（1.8, 3.3） mmol/L;AC：3.2（2.5, 3.5） mmol/L; P=0.035]水平存在统计学差异。CYP2C9位点不同基因型的患者之间谷丙转移酶水平[AA:16.9（11.4, 30.2） mmol/L;AC：10.4（9.4, 18.2） mmol/L; P=0.040]存在统计学差异。个体化治疗干预后,CYP3A5、AGTR1位点不同基因型影响患者的心率[CYP3A5: AA:（79.3±7.0） 次/min;AG：（69.8±6.8） 次/min;GG：（68.8±7.3） 次/min;P=0.010）]、收缩压[AGTR1: AA:（131.3±16.7） mmHg;AC：（140.6±11.8）mmHg;P=0.014]和舒张压[CYP3A5: AA:（90.0±8.3）mmHg;AG：（78.7±10.8） mmHg;GG：（74.9±10.7） mmHg;P=0.025; AGTR1: AA:（75.3±10.2） mmHg;AC：（86.3±10.6） mmHg;P=0.001]。结果 降压药物的相关基因位点是指导临床用药多样化、个体化的重要依据,临床医生在开具处方时需要考虑相关基因对药物疗效和不良反应的影响。