Futrakul Narisa, Tohsukhowong Piyaratana, Patumraj Suthiluk, Siriviriyakuk Prasong, Tipprukmas Numdee, Futrakul Prasit
Department of Physiology, King Chulalongkorn Memorial Hospital, Bangkok, Thailand.
Ren Fail. 2003 Sep;25(5):839-44. doi: 10.1081/jdi-120024298.
Hemodynamic maladjustment is a unique observation in chronically severe glomerulonephritides. It is characterized by a markedly elevated efferent arteriolar resistance (RE), an elevated intraglomerular hydrostatic pressure (PG) and a markedly decreased renal plasma flow (RPF), and peritubular capillary flow (PTCF). A correction of such hemodynamic maladjustment can be accomplished by administering a combination of vasodilators (angiotensin receptor antagonist, angiotensin converting enzyme inhibitor, and calcium channel blocker) in 14 chronic glomerulonephritides with severe renal function impairment (mean serum creatinine 3.6 + 1.3 mg/dL). Doses titration aim for maximal renal perfusion effect (increased RPF, PTCF) or maximal renal function improvement (increased CCr, reduced FE Mg) usually higher than needed for maximal blood pressure reduction. Evidence of oxidative stress is also corrected with high doses of vitamins C and E. After a mean period of treatment for 13.5 months, improvements in CCr (pre R(x) 22 +/- 10 vs. post R(x) 32 +/- 13 mL/min/1.73 m2), and FE Mg (pre R(x) 11.9 +/- 4% vs. post R(x) 10 +/- 3%) were observed in conjunction with the improvement in intrarenal hemodynamics namely RPF (pre R(x) 201 +/- 71 vs. post R(x) 288 +/- 99 mL/min/1.73 m2), PTCF (pre R(x) 161 +/- 57 vs. post R(x) 242 +/- 90 mL/ min/1.73 m2), PG (pre R(x) 56.7 +/- 0.5 vs. post R(x) 51 +/- 0.1 mm Hg), and RE (pre R(x) 12085 +/- 6503 vs. post R(x) 6550 +/- 1872 dyne.s.cm(-5)).
血流动力学失调是慢性重症肾小球肾炎中一种独特的表现。其特征为出球小动脉阻力（RE）显著升高、肾小球内静水压力（PG）升高、肾血浆流量（RPF）以及肾小管周围毛细血管流量（PTCF）显著降低。对于14例伴有严重肾功能损害（平均血清肌酐3.6±1.3mg/dL）的慢性肾小球肾炎患者，通过联合使用血管扩张剂（血管紧张素受体拮抗剂、血管紧张素转换酶抑制剂和钙通道阻滞剂）可纠正这种血流动力学失调。剂量滴定旨在实现最大的肾灌注效果（增加RPF、PTCF）或最大程度改善肾功能（增加肌酐清除率[CCr]、降低镁排泄分数[FE Mg]），通常高于最大程度降低血压所需的剂量。高剂量的维生素C和E也可纠正氧化应激的证据。经过平均13.5个月的治疗期后，观察到CCr（治疗前R(x)22±10 vs. 治疗后R(x)32±13 mL/min/1.73 m2）和FE Mg（治疗前R(x)11.9±4% vs. 治疗后R(x)10±3%）有所改善，同时肾内血流动力学也得到改善，即RPF（治疗前R(x)201±71 vs. 治疗后R(x)288±99 mL/min/1.73 m2）、PTCF（治疗前R(x)161±57 vs. 治疗后R(x)242±90 mL/min/1.73 m2）、PG（治疗前R(x)56.7±0.5 vs. 治疗后R(x)51±0.1 mmHg）和RE（治疗前R(x)12085±6503 vs. 治疗后R(x)6550±1872 dyne.s.cm(-5)）。
