“高滤过”肾损害高血压患者动态血压特点分析

Ambulatory blood pressure characteristics in hypertensive patients with ＂hyperfdtration＂ renal damage

目的分析“高滤过”肾损害高血压患者动态血压特点。方法回顾性分析2011年11月至2013年5月于首都医科大学附属北京安贞医院就诊的估算。肾小球滤过率（eGFR）≥90ml／（min·1．73m^2）的376例初诊且无合并症的高血压患者的临床资料。根据eGFR的不同，将患者分为高滤过组[102例，eGFR≥120ml／（min·1．73m^2）j和正常组[274例，90ml／（min·1．73m^2）≤eGFR〈120ml／（min·1．73m^2）]；根据尿微量白蛋白／尿肌酐比值（UACR）水平的不同，将高滤过组分为A1组（19例，UACR≤10mg／g）、A2组（21例，10mg／g〈UACR≤20mg／g）、A3组（28例，20mg／g〈UACR≤30mg／g）和A4组（34例，30mg／g〈UACR〈300mg／g）；将正常组分为B1组（45例，UACR≤10mg／g）、B2组（69例，10mg／g〈UACR≤20mg／g）、B3组（64例，20mg／g〈UACR≤30mg／g）和B4组（96例，30mg／g〈UACR〈300mg／g）。比较各组动态血压特点。结果高滤过组和正常组组内UACR水平逐渐升高，差异有统计学意义（P〈0．05）。在正常组亚组中，B4组夜间平均收缩压（nSBP）和夜间平均舒张压（nDBP）水平明显高于B1组；在高滤过组亚组中，A4组nSBP和nDBP水平明显高于A1组，差异均有统计学意义（均P〈0．05）。A4组nDBP水平明显高于B4组[（93±10）mmHg（1mmHg=0．133kPa）比（82±11）mmHg]，差异有统计学意义（P〈0．05）。在正常组亚组中，B4组收缩压差值（ASBP）和舒张压差值（ADBP）水平明显低于B1组；异常血压节律比例明显高于B1组、B2组、B3组[91．7％（88／96）比42．2％（27／64）、34．8％（24／69）、8．9％（4／45）]；在高滤过组亚组中，A4组ASBP和ADBP水平明显低于A1组；异常血压节律比例明显高于A1组、A2组、A3组[94．1％（32／34）比35．7％（10／28）、23．8％（5／21）、15．8％（3／19）]，差异均有统计学意义（均P〈0．05）。结论“高滤过”肾损害高血压患者夜间血压水平上升，并出现血压昼夜节律异常的现象，此时UACR仍在正常范围。因此节律异常，夜间血压水平应与eGFR一起作为监测、评价和干预高血压患者“高滤过”肾损害的指标。

Objective To analyze characteristics of ambulatory blood pressure in hypertensive patients with ＂hyperfiltration＂ renal damage. Methods Totally 376 patients who were diagnosed of hypertension in Beijing Anzhen Hospital, Capital Medical University from November 2011 to May 2013 were retrospectively analyzed. They were divided into hyperfiltration group according to glomerular filtration rate （eGFR） [ 102 cases, eGFR ≥ 120 ml/（ min · 1.73 m^2 ） ] and normal group [ 274 cases, 90 ml/（ min · 1.73 m^2 ） ≤ eGFR 〈 120 ml/（min · 1.73 m^2 ） ]. According to the level of urine albumin/creatinine rate（ UACR）, the hyperfihration group were divided into group Al（19 cases, UACR≤10 mg/g） , group A2（21 cases, 10 mg/g 〈 UACR≤20 mg/g）, group A3（28 cases, 20 mg/g 〈 UACR ≤ 30 mg/g） and group A4 （ 34 cases, 30 mg/g 〈 UACR 〈 300 mg/g） ; the normal group was divided into group B1 （45 cases, UACR ≤ 10 mg/g） , group B2 （69 cases, 10 mg/g 〈 UACR ≤20 mg/g）, group B3 （64 cases, 20 mg/g 〈 UACR ≤30 mg/g ） and group B4（96 cases, 30 mg/g 〈 UACR 〈 300 mg/g）. Ambulatory blood pressure characteristics were analyzed among groups. Results In patients with normal eGFR, nocturnal systolic blood pressure（nSBP） and nocturnal diastolic blood pressure（nDBP） in group B4 were significantly higher than those in group B1 （P 〈 0. 05）. In hyperfiltration group, nSBP and nDBP in group A4 were significantly higher than those in group A1 （P 〈 0. 05 ）. The level of nDBP in group A4 was significantly higher than that in group 134 [ （93 ± 10） mmHg vs （ 82 ± 11 ） mmHg ] （ P 〈 0. 05 ）. In patients with normal eGFR, ASBP and ADBP in group B4 were significantly lower than those in group B1 ; the proportion of abnormal blood pressure circadian rhythm in group B4 was significantly higher than that in group B1, B2, B3 [ 91.7% （88/96） vs 42. 2% （ 27/64）, 34. 8% （24/69）, 8.9% （4/45） ] （P 〈0. 05）. In hyperfiltration group, ASBP and ADBP in group A4 were significantly lower than those in group A1 ; the proportion of abnormal blood pressure circadian rhythm in group A4 was significantly higher than that in group A1, A2, A3194. 1% （32/34） vs 35.7% （ 10/38）, 23.8% （5/21）, 15.8% （3/19） ] （P 〈 0. 05 ）. Conclusions Nocturnal blood pressure elevation and abnormal circadian rhythm that occur in hypertensive patients can develop into ＂hyperfihration＂ stage, whereas UACR is still within the normal range. It is suggested that combined monitoring of blood pressure circadian rhythm and nocturnal blood pressure should be applied in assessment and intervention of ＂hyperfihration＂ renal dysfunetion along with eGFR.