高血壓腎病的循證降壓課件

高血壓腎病的循證降壓高血壓腎病的循證降壓從病理生理到ALLHAT與AASK研究的思考高血壓腎病的循證降壓PrimaryDiagnosisForPatientsWhoStartDialysis

Diabetes50.1%Hypertension27%Glomerulonephritis13%Other10%UnitedStatesRenalDataSystem.Annualdatareport.2000.NoofPatientsProjection95%CI198419861988199019921994199619982000200220042006200820100100200300400500600700R2=99.8%243,524281,355520,240NumberofDialysisPatients(thousands)高血壓病是ESRD第二大病因高血壓腎病的循證降壓ALLHAT和AASK研究病理生理高血壓腎病的循證降壓高血壓腎病的循證降壓病理生理HillGS,CurrOpinNephrolHypertens.2008May;17(3):266-70HypertensivenephrosclerosisIschemicFSGSHypertrophicFSGSChronichypertensionNarrowofinterlobular,afferentarterioleReductioninglomerularbloodflow高血壓腎病的循證降壓RenalbloodflowGFR01002001.51.00.50Flow,l/minArterialbloodpressure,mmHgAutoregulationofRBF&GFRi.e.theresistancesoftheinterlobularartery,afferentarteriole病理生理高血壓腎病的循證降壓病理生理高血壓腎病的循證降壓病理生理HillGS,CurrOpinNephrolHypertens.2008May;17(3):266-70HypertensivenephrosclerosisIschemicFSGSHypertrophicFSGSNarrowandstiffeningarterioleReductioninglomerularbloodflowLossofrenalautoregulationLossofrenalfunctionHarveyJM,Lancet1992Dec12;340(8833):1435-6高血壓腎病的循證降壓

讓我們看看大樣本臨床試驗ALLHAT研究和AASK研究病理生理臨床試驗

IschemicHypertrophic能否找到臨床指標來判斷那種模式為主呢?高血壓腎病的循證降壓RahmanMetal.ArchInternMed2005;165:936-46AntihypertensiveandLipid-LoweringtreatmenttopreventHeartAttackTrialALLHAT42,418patientswithhypertensionSBP>140mmHgand/orDBP>90mmHgORTookmedicationforhypertensionandhadatleastoneadditionalriskfactorforCHDAge>55yearsNHLBIfundedtrialEndpoints:Primary–FatalcoronaryheartdiseaseandnonfatalMI高血壓腎病的循證降壓eGFR(ml/min/1.73m2)RahmanMetal.ArchInternMed2005;165:936-46*p<0.05vs.Chlorthalidone***BaselineeGFR≥90(ml/min/1.73m2)ALLHAT高血壓腎病的循證降壓eGFR(ml/min/1.73m2)RahmanMetal.ArchInternMed2005;165:936-46*p<0.05vs.Chlorthalidone***BaselineeGFR60-89(ml/min/1.73m2)

TotalΔGFR(mL/min/y)

C-1.54

A-0.55

L-1.471styearΔGFR(mL/min/y)C-2.3A+1.5L-1.9FollowingΔGFR(mL/min/y)C-1.3

A-1.2

L-1.4ALLHAT高血壓腎病的循證降壓eGFR(ml/min/1.73m2)RahmanMetal.ArchInternMed2005;165:936-46*p<0.05vs.Chlorthalidone***BaselineeGFR<60(ml/min/1.73m2)TotalΔGFR(mL/min/y)

C-0.50

A+0.23

L-0.451styearΔGFR(mL/min/y)C+0.5A+4.3L+1.0FollowingΔGFR(mL/min/y)C-0.8

A-1.1

L-0.9ALLHAT高血壓腎病的循證降壓對腎臟來說,ALLHAT研究有兩點遺憾沒有提供尿蛋白的數(shù)據(jù)沒有eGFR<40ml/min的數(shù)據(jù)(因為入選對象血肌酐<2mg/dl)AASK研究可以彌補這兩點遺憾高血壓腎病的循證降壓EntryCriteriaAfrican-American(selfreport)18-70yroldwithDBP>95mmHgGFR20-65ml/min/1.73m2Non-diabeticBaselineurineprotein/creatinine<2.5PrimaryRenalOutcomeRateofdecline(slope)iniothalomateGFRAfricanAmericanStudyofKidneydiseaseandhypertension

N=1094AASKJAMA.

2001;285:2719-2728.高血壓腎病的循證降壓eGFR(ml/min/1.73m2)031224360510-5-10BaselineUp/Cr≤0.22ΔGFR(mL/min/y)

Amlodipine+0.20Ramipril-1.02

TotalslopeAmlodipinevsramipril:=3.6,p=0.006

JAMA.

2001;285:2719-2728.MonthsAASK高血壓腎病的循證降壓eGFR(ml/min/1.73m2)03122436BaselineUp/Cr>0.2205-5-10-15-20ΔGFR(mL/min/y)Amlodipine-5.62

Ramipril-3.60Totalslope

Amlodipinevsramipril:

=-6.06,p=0.006

JAMA.

2001;285:2719-2728.MonthsAASK高血壓腎病的循證降壓JAMA.

2001;285:2719-2728eGFR(ml/min/1.73m2)031224360510-5-10MeanBaselineGFR≥40ml/minper1.73m2ΔGFR(mL/min/y)

Amlodipine-0.55

Ramipril

-1.53TotalslopeAmlodipinevsramipril:

=-2.91,p=0.003

MonthsAASK高血壓腎病的循證降壓eGFR(ml/min/1.73m2)0312243605-5-10-15-20JAMA.

2001;285:2719-2728.MonthsMeanBaselineGFR<40ml/minper1.73m2ΔGFR(mL/min/y)

Amlodipine-4.33

Ramipril

-2.73TotalslopeAmlodipinevsramipril:

4.83,p=0.003

AASK高血壓腎病的循證降壓沒有明顯蛋白尿(UP/Cr

0.22)和腎功能損害早期（GFR≥40ml/min）高血壓腎病明顯蛋白尿(UP/Cr>0.22)或腎功能損害晚期（GFR<40ml/min）CCB獲益更大些ACEI獲益更大些ischemichypertrophic啟示高血壓腎病的循證降壓Upro/cr0.8,Ccr50ml/min.臨床實踐良性腎小動脈硬化患者Upro/cr0.10,Ccr55ml/min.長效CCB…...ACEI基礎的方案……5年后高血壓腎病的循證降壓

臨床實踐高血壓腎病的循證降壓結論高血壓腎病的循證降壓謝謝！高血壓腎病的循證降壓△GFR(ml/min/1.73m2)031224360510-5-10BaselineUp/Cr≤0.22ΔGFR(mL/min/y)

Amlodipine+0.20Ramipril-1.02

TotalslopeAmlodipinevsramipril: