（高血压英文课件）Hypertension-in-CKD.ppt

1、Hypertension in CKDMichael J Casey,MDWake Nephrology AssociatesHypertension Stats HTN affects approximately 1 billion worldwide$500 billion in direct costs Continuous,consistent and independent relationship between BP and Cads For those age 40-70,each increased increment of 20/10 mmHg in BP doubles

2、the risk of CVD across the entire BP range of 115/75 to 185/115.Only 35%of hypertensive patients on treatment are under control.Hypertension as Defined by JNC VII 120/80 -normal;“optimal”121-139/80-89 -“pre-hypertension”Controversial More a health policy statement 140-160/90-100-Stage 1 Hypertension

3、 160/100-Stage 2 HypertensionMeasurement of Blood Pressure Seated position with arm supported ideal Allow patient to settle for several minutes Proper sized cuff Bladder to encircle 80 100%arm Bladder width 40-50%of arm Confirm 2 readings 5 minutes apart in both arms for initial diagnosis If taken i

4、n wrist or legs,the cuff must be at the level of the heartBP MeasurementHome BP Monitoring Self readings or continuous ambulatory monitoring Helpful adjunct to office readings More readings in patients usual environment Better correlated with cardiovascular outcomes Improves patient compliance Helps

5、 clarify symptoms Defines masked and white coat hypertensionHome BP Monitoring Patients need to be taught proper methods No wrist cuffs Semi-automated electronic cuffs Cuff needs to be checked against office readings Frequency of monitoring can vary All current outcome data/guidelines/trails are fro

6、m office readingsAmbulatory BP MonitoringAmbulatory BP MonitoringAmbulatory BP Monitoring More reproducible than office measurements Helpful in early diagnosis Unexplained microalbuminuria or LVH White Coat Hypertension Resistant Hypertension No long term studies yetPrevalence of HTN in CKDHypertens

7、ion in CKD 80%of patients with CKD have HBP Most start with essential hypertension As GFR decreases it is more dependent on salt/water retention from decreased GFR CKD patients also have derangements in the Renin/Angiotensin/Aldosterone systemTreatment of Hypertension Goal depends on disease state 1

8、30/80 if DM,CKD,CVDz 25mg Ineffective at GFR 50 Can boost efficacy of loop diureticsLoop Diuretics Necessary to maintain volume status in GFR 50 Furosemide is classic but short half life so poor for HBP Bumetanide is same but better absorbed Torsemide has much longer half-life and is my choice now t

9、hat it is generic Titrate to increase UOP then increase frequency Low potassium is main issue,especially with thiazides(metolazone)Beta Blockers Selective Beta Blockers Atenolol,metoprolol,bisoprolol,nebivolol Non selective Beta Blockers Propranolol Alpha Beta Blockers Labetolol,carvedololBeta Block

10、ers Next class in CKD patients Reduces HR,SV and also renin Reduces incidence of sudden cardiac death and arrhythmias Reduces CV events in CHF,post-MI Counter-acts reflex increase in HR/CO induced by vasodilators and diureticsBeta Blockers Carvedolol,labetolol are better for HBP Atenolol,metoprolol

11、better for CHF,HR reduction and arrhythmia Propranolol for ascites/cirrhosis,anxiety Bradycardia and fatigue are main side effectsCentral Adrenergic Agents Clonidine is predominant drug Probably same benefits as b blockers No studies and never will be Synergy with b blockers debatable Dry mouth,fati

12、gue,t.i.d.,bradycardia Good for acute HBP/prn use Patch available Methyldopa for HBP in pregnancyDihydropyridine Calcium Channel Blockers Nifedipine,amlodipine,felodipine Direct vasodilators Very effective prob 4th drug of choice Can cause peripheral edema especially in females No effect on HR,CHF I

13、ncrease GFR,proteinuriaGlomerular PerfusionNon-Dihydropyridine CCBs Diltiazem and Verapamil Reduce HR and Lower BP Arrhythmia control Reduction in proteinuria but no renal outcomes Edema,bradycardia,gingival hyperplasia,CyP450 interactionsOther Vasodilators Alpha blockers doxazosin,terazosin,prazosi

14、n Help with BHP Once daily Orthostatic hypertension,tachycardia,CHF Hydralazine Improved outcomes in AA with CHF BID or TID Lupus syndrome Moderately effectiveMinoxidil Most potent antihypertensive agent Severe rebound tachycardia and edema Need beta blocker and loop diuretic Hair growth Pericarditi

15、s InexpensiveHypertension in ESRD Great area of debate RAAS Agents and Beta blockers may improve outcomes in non-RCTs What is correct measurement?Pre-HD BP Post-HD BP Home BP When to take/hold BP MedsHypertension in ESRDPreHD systolic BP cannot reliably predict Ambulatory BP-40-30-20-100102030401301

16、35140145150155160165Pre-dialysis Systolic BPAverage of Ambulatory and Dialysis Unit BPDialysis Unit BP minus Ambulatory BPAgarwal R,et al.CJASN 1:389-398,2006Hypertension in ESRDDialysis Unit BP was of no value in predicting echo-LVHAgarwal R,et al.Hypertension 47:62-68,20060.00.20.40.60.81.00.00.20

17、.40.60.81.0-PostPreStandardized BP1-Specificity0.00.20.40.60.81.00.00.20.40.60.81.0-PostPreRoutine BPSensitivityHypertension in ESRDOut of dialysis unit BP are of greater prognostic significance00.511.522.53PreHDRoutinePost HDRoutinePreHDStandardizedPost HDStandardizedHomeAmbulatoryQ1Q2Q3Q4Hazard Ra

18、tio of All Cause MortalityP=0.05P=0.011P=0.999P=0.182P=0.228P=0.339“Best home BP”125-145 mm HgBest ABP 115-125 mm HgAlborzi P et al CJASN 6:1228-1243,2007Hypertension in ESRD J-shaped curve of survival vs BP in ESRD Better survival with moderate HBP Only compared to other ESRD?Skewed by young patien

19、ts?Skewed by cardiomyopathy Most HBP is due to inadequate volume control Decrease interdialytic weight gain Challenge weight Longer HD times(daily,nocturnal,PD)Relationship between blood pressure and mortality in dialysis patients.Luther JM Kidn Int 2008;73:667-668Treatment of HBP in ESRD Gradually

20、challenge weight each HD No edema Cramping Low BP Management of intradialytic HBP UF profiling Na+modeling Lower dialysate temperature Carnitene levelsTreatment of HBP in ESRD Do not hold Beta blockers/Clonidine before dialysis(MY OPINION)Short acting meds Increase risk rebound HBP,Tachycardia Take

21、once daily meds at bedtime for consistency from day to day Wean off meds without cardiovascular benefitsTreatment of HBP in ESRDTreatment of HBP in ESRDSystolic BP was reduced 7 mmHg in 4w with UF130140150048Systolic Blood Pressure(mm Hg)Weeks-7.4(-2.1 to-12.7)-7.1(-1.8 to-12.5)-0.5(-5.6 to 4.5)Cont

22、rolUltrafiltration-10.7(-7.4 to-13.9)-2.8(-0.5 to-6.1)-3.8(0.7 to-8.4)-3.1(1.6 to-7.8)-6.9(-12.4 to-1.3)P=0.018+0.3NSAgarwal R et al Hypertension 2009Treatment of HBP in ESRDPossible related adverse effectsControlsUFVery high BP5(10%)1(2%)Hypotension/Seizure01(2%)Chest pain/Hypotension01(2%)Hypotens

23、ion/Saline in ER 01(2%)Clotted access2 events(2 pts)10 events(6 pts)Agarwal R et al Hypertension 2009Treatment of HBP in ESRD Small group of patients have BP rise with volume removal Exaggerated hormonal response decreased intravascular volume Manifest no edema BP normal at HD onset and usually with

24、in several hours after HD Benefit from increased DW/decreased UF Response to RAAS and Beta blockersSummary Hypertension is a complex disease High morbidity,mortality,economic impact Treatment is art+science RAAS agents key in CKD Volume regulation is crucial Scarce data on what to do in ESRDTHANK YOUBrenda MartinSun Tech ABPM MonitorsANNAPlease email me for a copy of my slidesM