慢性肾脏病患者血压昼夜节律异常的研究

目的 观察慢性肾脏病(CKD)患者24 h血压动态变化，探讨昼夜节律异常与肾功能损害的关系。方法 随机选择本院肾脏科CKD患者236例，高血压科原发性高血压住院患者43例。病例分组:正常对照组(NC)14例；原发性高血压组(EHC)43例；CKD血压正常组(NCKD)130例；CKD伴血压升高组(HCKD)106例。动态血压监测(ABPM)采用携带式的动态血压检测仪，ABP Report Mangement System Version 1.03.03进行数据分析。夜间血压下降率:(白昼平均值-夜间平均值)/白昼平均值，下降率≥10%，称勺型血压；<10%，称非勺型血压。结果 在血压正常的患者中，NCKD组的平均夜间收缩压和舒张压数值均高于NC组[(111.2±10.8)比 (91.6±7.5)，(68.7±9.5) 比 (56.2±4.6)mm Hg，P < 0.05]；而日间收缩压和舒张压无明显差异。在高血压患者中，HCKD组患者夜间收缩压和舒张压数值均高于EHC组[(141.9±16.5) 比(118.6±16.4)， (84.5±10.6)比(73.0±11.1)mm Hg， P < 0.05]。CKD患者无论血压正常或升高，其心率均较其对照组明显加快，尤其是夜间心率无明显下降。NCKD组、HCKD组与NC组、EHC组相比，夜间收缩压和舒张压下降数值较小，尤其是CKD伴血压升高组，呈典型的非勺型血压模式。NC组血压节律消失者占7.14%，EHC组为37.2%，NCKD组为70.0%，HCKD组为81.6%。结论 CKD患者无论血压正常或升高，夜间收缩压和舒张压下降减少或消失，呈典型的非勺型血压；血压昼夜节律异常率明显高于原发性高血压患者。在积极降低血压值的同时，还需降低血压负荷和调整血压昼夜节律，以延缓肾功能恶化。

Ambulatory blood pressure measurement in patients with chronic kidney disease

Objective To observe the change of 24-hour blood pressure and to explore the relation between abnormality of circadian rhythm and renal injury in patients with chronic kidney disease. Methods Circadian blood pressure rhythm was studied by ambulatory 24-hour monitoring in normotensive(n=130) and hypertensive (n=106) patients with chronic kidney disease， and in matched control groups (14 healthy subjects and 43 patients with essential hypertension) without renal disease. Ambulatory blood pressure monitoring(ABPM) was performed with a portable oscillometric recorder(Spacelab 90217). ABP Report Management System Version1.03.03 was used to analyze the 24-hour data. The term “dipper” was described as BP during sleep drops at least 10% below daytime pressure. The term “non-dipper” referred to those subjects in whom the nocturnal decline in BP is reversed， absent， or blunted (ie， less than 10%). Results In normotensive subjects， average night systolic and diastolic BP values were constantly higher in the patients with chronic kidney disease than those in the controls (111.2±10.8 vs 91.6±7.5，68.7±9.5 vs 56.2±4.6，P < 0.05). Average daytime SBP and DBP levels did not differ considerably in CKD patients and essential hypertensivers. The frequency of non-dippers was 70.0% in NCKD group， 81.6% in HCKD group， 37.2% in EH group， 7.14% in NC subjects respectively. The normotensive and hypertensive renal patients had higher heart rate(HR) than the corresponding groups，especially at nighttime， with a significant blunted nocturnal decline as compared to control subjects. The NCKD group and HCKD group revealed a much less pronounced decline in nocturnal mean BP values，with a typical non-dipper pattern.Hypertensives with chronic kidney disease displayed pronounced abnormalities in the 24-hour BP pattern， with markedly blunted nocturnal fall and flattened or reversed day-night circadian rhythm BP values. Conclusions Normotensive patients with chronic kidney disease are exposed to a relative hypertension at nighttime and that renal hypertensive subjects can be underestimated in their hypertensive status if the measurement of BP is confined to daytime. There is a compelling need for studying if treating nocturnal hypertension in CKD can prevent renal disease progression.