Locatelli F, Bommer J, London G M, Martín-Malo A, Wanner C, Yaqoob M, Zoccali C
Azienda Ospedale di Lecco, Ospedale A. Manzoni, Lecco, Italy, and. University Hospital, Heidelberg, Germany.
Nephrol Dial Transplant. 2001 Mar;16(3):459-68. doi: 10.1093/ndt/16.3.459.
Cardiovascular disease (CVD), as the leading cause of morbidity and mortality in patients on renal replacement therapy (RRT), has a central role in everyday nephrological practice.
Consensus was reached on key points relating to the clinical approach and treatment of the main cardiovascular risk factors in RRT patients (hypertension, anaemia, hyperparathyroidism, dyslipidaemia, new emerging risk factors). In addition, the role of convective treatments on cardiovascular outcomes was examined.
Hypertension should be managed by aiming at blood pressure values of < or =140/90 mmHg (< or =160/90 mmHg in the elderly), firstly by ensuring target dry body weight is achieved. No single class of drug has proved superior to others in RRT patients, provided that the blood pressure target is achieved, although ACE inhibitors have shown specific organ protection in high-risk patients (HOPE study) and are well tolerated. Anaemia should be managed by using erythropoietin and iron supplements, aiming at haemoglobin levels of 12 g/dl and keeping serum ferritin levels < 500 ng/ml. The management of hyperparathyroidism is currently unsatisfactory, as calcium supplements have the potential to increase cardiovascular calcification. While awaiting new calcium- and aluminium-free phosphate binders, it is essential to ensure dialysis adequacy. Clinical studies are in progress to assess the real impact of lipid-lowering drugs in RRT. In the meantime, serum LDL-cholesterol < 160 mg/dl and triglycerides < 500 mg/dl may be desirable targets. The impact of new emerging risk factors (inflammation and chronic infection, hyperhomocysteinaemia, metabolic waste-product accumulation) and their proper management are still under research. Convective dialysis treatments may confer some degree of protection from dialysis-related amyloidosis and mortality, but clinical data on this important issue are still controversial and no definitive conclusions can be drawn at present.
CVD prevention and treatment is a great challenge for the nephrologist. Achieving evidence-based consensus can help in encouraging the implementation of best clinical practice in line with the progress of current knowledge.
心血管疾病（CVD）是接受肾脏替代治疗（RRT）患者发病和死亡的主要原因，在日常肾脏病实践中起着核心作用。
就RRT患者主要心血管危险因素（高血压、贫血、甲状旁腺功能亢进、血脂异常、新出现的危险因素）的临床处理和治疗相关要点达成了共识。此外，还研究了对流治疗对心血管结局的作用。
高血压的管理应以血压值≤140/90 mmHg（老年人≤160/90 mmHg）为目标，首先要确保达到目标干体重。在RRT患者中，只要达到血压目标，没有哪一类药物被证明比其他药物更优越，尽管血管紧张素转换酶抑制剂在高危患者中显示出特定的器官保护作用（心脏结局预防评估研究）且耐受性良好。贫血的管理应使用促红细胞生成素和铁补充剂，目标是血红蛋白水平达到12 g/dl，并使血清铁蛋白水平＜500 ng/ml。甲状旁腺功能亢进的管理目前并不理想，因为补钙有可能增加心血管钙化。在等待新型无钙和无铝磷结合剂的同时，确保透析充分性至关重要。目前正在进行临床研究以评估降脂药物在RRT中的实际影响。与此同时，血清低密度脂蛋白胆固醇＜160 mg/dl和甘油三酯＜500 mg/dl可能是理想目标。新出现的危险因素（炎症和慢性感染、高同型半胱氨酸血症、代谢废物蓄积）的影响及其恰当管理仍在研究中。对流透析治疗可能对预防透析相关淀粉样变和降低死亡率有一定程度的保护作用，但关于这一重要问题的临床数据仍存在争议，目前无法得出明确结论。
CVD的预防和治疗对肾脏病学家来说是一项巨大挑战。达成基于证据的共识有助于鼓励根据当前知识的进展实施最佳临床实践。
