关于血液透析患者高血压管理的研究进展

Research progress on hypertension management in hemodialysis patients

血液透析患者的高血压患病率很高,对此类患者的高血压进行有效的管控能够降低其心脑血管疾病的死亡率。目前针对透析患者血压控制的理想靶目标还不明确,血压过高过低均会增加患者死亡率。透析间期的动态血压监测较透析期的血压监测更有利于高血压的诊断与管理。建议日间平均血压<135/85 mmHg,夜间平均血压<120/80 mmHg。高血压的治疗应以透析本身做为最重要的治疗手段,首要策略是容量控制,干体质量达标。在探究干体质量的过程中,应遵照循序渐进的原则,避免过快。个性化的钠透析液处方及高频率长时透析有利于血压的控制。如果患者对于容量控制策略没有反应,则需考虑降压药物的应用。降压药物的选择要充分考虑到不同药物的有效性、安全性、心脏的保护作用、药代动力学特性、透析器清除率以及潜在的并发症。除了利尿剂之外,近乎所有种类的降压药均对透析患者高血压的治疗有效。与一般人群相比较,β受体阻滞剂对透析患者的高血压治疗可能提供更大的心脏保护作用。本文回顾了近10年来的文献,对血液透析患者高血压管理方面的研究进展进行了综述。

The morbidity of hypertension in patients with chronic hemodialysis is very high.Effective management of hypertension in such patients can reduce the mortality of cardio-cerebrovascular diseases.Blood pressure target for dialysis patients is not clear,but too high or too low blood pressure will increase mortality of such patients.Ambulatory blood pressure monitoring(ABPM)during interdialysis sessions is more beneficial to the diagnosis and management of hypertension than that during intradialysis sessions.Maintaining interdialytic ABPM<135/85 mmHg in daytime and ABPM<120/80 mmHg in nighttime are recommended.Dialysis is the most important treatment of hypertension in chronic hemodialysis patients.The first strategy is volume control and target dry weight achievement,which should be done gradually.In addition,personalized sodium dialysate prescription and high-frequency long-term dialysis are beneficial to the control of blood pressure.If patients do not respond to volume control strategy,antihypertensive drugs will be required.The selection of antihypertensive drugs should take into account the effectiveness,safety,cardiac protection,pharmacokinetics,clearance rate of dialyzer and potential complications of different drugs.Except for diuretics,nearly all kinds of antihypertensive drugs are effective for the treatment of hypertension in dialysis patients.Beta receptor blockers may provide greater cardiac protection in dialysis patients compared with normal population.In this paper,we review the literature in the last 10 years,and summarize the research progress in the management of hypertension in patients with chronic hemodialysis.