Total blood pressure management in hypertensive patients wit2017-05-28 09:49
Diabetic nephropathy (DKD) is one of the most common microvascular complications of diabetes. It plays an important role in end-stage renal disease and is an important cause of death in diabetic patients. For hypertensive patients with DKD, the damage of DKD to the large vessels is no less than the damage to the microvasculature, resulting in a vicious cycle of kidney and cardiovascular damage.
Blood pressure target values in hypertensive patients with diabetic nephropathy
The domestic and foreign hypertension guidelines suggest that patients with diabetes and high blood pressure, when the <1g/d urine protein, blood pressure should be controlled less than 130/80mmHg; when the urine protein is more than 1g/d, the blood pressure should be controlled under 125/75mmHg. The UK Prospective Diabetes Study (UKPDS) a test further proposed, if tolerated, should the systolic blood pressure (SBP) target to less than 120mmHg. However, in recent years, some updated studies have not supported the view that all patients with chronic kidney disease have antihypertensive benefits.
Some studies have shown that there is no significant difference between improving blood pressure and standard blood pressure in improving glomerular filtration rate. Aggressive blood pressure control may not benefit patients, suggesting proper relaxation of blood pressure control targets in patients with chronic kidney disease, and 140mmHg may be the cut-off point for the increased risk of developing end-stage renal disease (ESKD). There are similar small studies at home that support this view.
Different observations seem to be related to the patient's specific condition, so different blood pressure target values are recommended for different patients. According to urinary albumin / creatinine ratio are used to assess the appropriateness of antihypertensive treatment standards is a more scientific means, to strengthen the blood pressure lowering on urine protein and creatinine ratio of more than 0.22 of patients with chronic kidney disease, and the urine protein and creatinine ratio of <0.22 patients is appropriate to relax the control of blood pressure target value.
Antihypertensive drugs in hypertensive patients with diabetic nephropathy
The preferred angiotensin converting enzyme inhibitors (ACEI) / angiotensin II receptor blocker (ARB): hypertensive patients with DKD, the general should take antihypertensive strategies to be used can reduce blood pressure and protect the renal drug of choice of renin-angiotensin system (RAS) inhibitors. These drugs can simultaneously dilate the afferent and efferent arterioles and take advantage of the expansion of the small ball arteries to resolve the "three high" states (high intra capsular pressure, high perfusion, high filtration) of renal damage. In addition, these drugs also have the advantages of improving insulin sensitivity, improving vascular endothelial function and reversing left ventricular hypertrophy.
It is important to note that the combined use of ACEI and ARB is not recommended. In 2008, the American Heart Association (ACC) published the results of the world's largest study to date. The study showed no significant difference between the combined ACEI and ARB primary endpoints. It shows that the combination therapy can not produce synergistic protection, but may increase adverse reactions, especially hypotension, kidney damage and hyperkalemia.
Calcium antagonists (CCB): CCB does not dilate the glomerular efferent artery, but the hypotensive effect of the long-acting CCB is positive. Studies have shown that lowering blood pressure in patients with kidney disease may be more important than altering the intrarenal pressure, which can protect the kidneys by improving the hemodynamics of the glomerulus. CCB has the following advantages: reducing the long-term renal glomerular capillary tension, against the value; reducing the accumulating of macromolecules in the glomerular, renal sclerosis; improve uremic patients with renal calcium deposition; inhibit platelet derived growth factor, inhibit the mitogenic effect, prevent glomerular sclerosis; reduce free radical etc.. Therefore, long term CCB is the best alternative when there is no use of ARB/ACEI.
Combination therapy is essential
In addition to the positive control of blood pressure, for patients with hypertension accompanied by DKD, we must also pay attention to the following treatment:
Total glycemic control: diabetes control and complications test (DCCT) study found that type 1 diabetes mellitus (T1DM) intensive insulin treatment, the risk of diabetic nephropathy can be reduced by 35% to 55%. If the clinical diabetic nephropathy has been developed and has obvious proteinuria, the control of blood sugar will be less helpful for the development of the disease. Some scholars believe that after the occurrence of diabetic nephropathy, hypoglycemic drugs should be switched to insulin.
Control of dyslipidemia and obesity: the National Kidney Foundation in the development of diabetes and chronic kidney disease clinical practice guidelines in the process, in addition to the emphasis of chronic kidney disease patients should strengthen the control of blood glucose and blood pressure control, especially points out the importance of correcting dyslipidemia and weight control quality index. For overweight and obese patients (BMI>24.9kg/m2), diet must be balanced by a balanced calorie diet.