Csiky B, Kovács T, Wágner L, Vass T, Nagy J
Nephrological Centre and Second Department of Medicine, University Medical School of Pécs, Hungary.
Nephrol Dial Transplant. 1999 Jan;14(1):86-90. doi: 10.1093/ndt/14.1.86.
Hypertension is a recognized marker of poor prognosis in IgA nephropathy.
The present study investigated the prevalence of white-coat hypertension, the diurnal rhythm of blood pressure (BP), the effectiveness of antihypertensive drug therapy, and the effect of the above on the progression of the kidney disease in IgA nephropathy. One hundred twenty-six IgA nephropathy patients were selected consecutively for 24-h ambulatory blood pressure monitoring (ABPM). Fifty-five patients were normotensive and 71 were treated hypertensives. Their antihypertensive drugs were angiotensin-converting enzyme inhibitors (ACEI) alone or in combination with calcium-channel blockers (CCB).
The mean night-time BP of normotensives (108+/-9/67+/-6 mmHg) was significantly lower than their day-time BP (125+/-8/82+/-7 mmHg, P<0.05). There was no significant difference between the mean day-time and night-time BP in hypertensive patients (125+/-9/82+/-7 mmHg vs 128+/-10/85+/-9 mmHg). The circadian variation of BP was preserved ('dippers') in 82% of the normotensive and 7% of the hypertensive patients (P<0.001). There were 10 'white-coat hypertensives' among the patients classified as normotensives with ABPM (mean office blood pressure 149+/-7/96+/-8 mmHg, 24-h blood pressure 127+/-6/83+/-5 mmHg, P<0.05) and 14 among treated hypertensives (mean office BP 152+/-8/98+/-6 mmHg, 24-h BP 130+/-4/85+/-8 mmHg, P<0.05). There was no difference in mean day-time BP among normotensive and treated hypertensive patients (125+/-8/81+/-5 mmHg vs 128+/-10/85+/-9 mmHg). Hypertensives had significantly higher night-time BP (125+/-9/85+/-9 mmHg) than normotensives (108+/-9/67+/-6 mmHg, P<0.001). There was no difference in serum creatinine levels among the different groups at the time of the ABPM. However, thirty-six+/-4.1 months after the ABPM, hypertensive patients (n=52) had higher serum creatinine levels (124+/-32 micromol/l) than at the time of the ABPM (101+/-28 micromol/l). The serum creatinine of normotensive patients (n=43) did not change during the follow-up period. 'Non-dipper' normotensives (n=10) had significantly higher serum creatinine levels at the end of the follow-up period than at its beginning (106+/-17 micromol/l vs 89+/-18 micromol/l, P<0.05). There was no increase in serum creatinine of 'dipper' normotensives. The mean serum creatinine of 'white-coat hypertensives' was significantly higher at the end of the study period than at its beginning.
There is no diurnal blood pressure variation in most of the hypertensive IgA nephropathy patients. ACEI and CCB treatment have better effect on day-time than night-time hypertension. The lack of the circadian rhythm and 'white-coat hypertension' seems to accelerate the progression of IgA nephropathy.
高血压是IgA肾病预后不良的一个公认指标。
本研究调查了白大衣高血压的患病率、血压（BP）的昼夜节律、抗高血压药物治疗的有效性，以及上述因素对IgA肾病患者肾脏疾病进展的影响。连续选取126例IgA肾病患者进行24小时动态血压监测（ABPM）。55例患者血压正常，71例为接受治疗的高血压患者。他们使用的抗高血压药物为单独的血管紧张素转换酶抑制剂（ACEI）或与钙通道阻滞剂（CCB）联合使用。
血压正常者的夜间平均血压（108±9/67±6 mmHg）显著低于日间血压（125±8/82±7 mmHg，P<0.05）。高血压患者的日间和夜间平均血压之间无显著差异（125±9/82±7 mmHg对128±10/85±9 mmHg）。82%的血压正常者和7%的高血压患者的血压昼夜变化得以保留（“杓型”）（P<0.001）。在通过ABPM分类为血压正常的患者中有10例“白大衣高血压患者”（平均诊室血压149±7/96±8 mmHg，24小时血压127±6/83±5 mmHg，P<0.05），在接受治疗的高血压患者中有14例（平均诊室血压152±8/98±6 mmHg，24小时血压130±4/85±8 mmHg，P<0.05）。血压正常者和接受治疗的高血压患者的日间平均血压无差异（125±8/81±5 mmHg对128±10/85±9 mmHg）。高血压患者的夜间血压（125±9/85±9 mmHg）显著高于血压正常者（108±9/67±6 mmHg，P<0.001）。在进行ABPM时，不同组之间的血清肌酐水平无差异。然而，在ABPM后36±4.1个月，高血压患者（n=52）的血清肌酐水平（124±32 μmol/l）高于ABPM时（101±28 μmol/l）。血压正常患者（n=43）的血清肌酐在随访期间未发生变化。“非杓型”血压正常者（n=10）在随访期末的血清肌酐水平显著高于期初（106±17 μmol/l对89±18 μmol/l，P<0.05）。“杓型”血压正常者的血清肌酐没有升高。“白大衣高血压患者”在研究期末的平均血清肌酐显著高于期初。
大多数高血压IgA肾病患者不存在血压昼夜变化。ACEI和CCB治疗对日间高血压的效果优于夜间高血压。昼夜节律的缺失和“白大衣高血压”似乎会加速IgA肾病的进展。
