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ALLHAT和AASK研究病理生理高血壓腎病的循證降壓病理生理HillGS,CurrOpinNephrolHypertens.2008May;17(3):266-70HypertensivenephrosclerosisIschemicFSGSHypertrophicFSGSChronichypertensionNarrowofinterlobular,afferentarterioleReductioninglomerularbloodflowRenalbloodflowGFR01002001.51.00.50Flow,l/minArterialbloodpressure,mmHgAutoregulationofRBF&GFRi.e.theresistancesoftheinterlobularartery,afferentarteriole病理生理/kidney.html病理生理病理生理HillGS,CurrOpinNephrolHypertens.2008May;17(3):266-70HypertensivenephrosclerosisIschemicFSGSHypertrophicFSGSNarrowandstiffeningarterioleReductioninglomerularbloodflowLossofrenalautoregulationLossofrenalfunctionHarveyJM,Lancet1992Dec12;340(8833):1435-6

讓我們看看大樣本臨床試驗(yàn)ALLHAT研究和AASK研究病理生理臨床試驗(yàn)

IschemicHypertrophic能否找到臨床指標(biāo)來(lái)判斷那種模式為主呢?RahmanMetal.ArchInternMed2005;165:936-46AntihypertensiveandLipid-LoweringtreatmenttopreventHeartAttackTrialALLHAT42,418patientswithhypertensionSBP>140mmHgand/orDBP>90mmHgORTookmedicationforhypertensionandhadatleastoneadditionalriskfactorforCHDAge>55yearsNHLBIfundedtrialEndpoints:Primary–FatalcoronaryheartdiseaseandnonfatalMIeGFR(ml/min/1.73m2)RahmanMetal.ArchInternMed2005;165:936-46*p<0.05vs.Chlorthalidone***BaselineeGFR≥90(ml/min/1.73m2)ALLHATeGFR(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-1.4ALLHATeGFR(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對(duì)腎臟來(lái)說(shuō),ALLHAT研究有兩點(diǎn)遺憾沒(méi)有提供尿蛋白的數(shù)據(jù)沒(méi)有eGFR<40ml/min的數(shù)據(jù)(因?yàn)槿脒x對(duì)象血肌酐<2mg/dl)AASK研究可以彌補(bǔ)這兩點(diǎn)遺憾EntryCriteriaAfrican-American(selfreport)18-70yroldwithDBP>95mmHgGFR20-65ml/min/1.73m2Non-diabeticBaselineurineprotein/creatinine<2.5PrimaryRenalOutcomeRateofdecline(slope)iniothalomateGFRAfricanAmericanStudyofKidneydiseaseandhypertension

N=1094AASKJAMA.

2001;285:2719-2728.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.MonthsAASKeGFR(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.MonthsAASKJAMA.

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

MonthsAASKeGFR(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沒(méi)有明顯蛋白尿(UP/Cr0.22)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Upro/cr0.8,Ccr50ml/min.臨床實(shí)踐良性腎小動(dòng)脈硬化患者Upro/cr0.10,Ccr55ml/min.長(zhǎng)效CCB…...ACEI基礎(chǔ)的方案……5年后

臨床實(shí)踐結(jié)論謝謝！△GFR(ml/min/1.73m2)031224360510-5-10BaselineUp/Cr≤0.22ΔGFR(mL/min/y)

Amlodipine+0.20Ramipril-1.02

TotalslopeAmlodipine