Bakris G L, Hart P, Ritz E
Department of Medicine, Hypertension Center, Endocrine Division, University of Chicago School of Medicine, Chicago, Illinois 60637, USA.
Kidney Int. 2006 Dec;70(11):1905-13. doi: 10.1038/sj.ki.5001835. Epub 2006 Oct 4.
The sympathetic nervous system modulates renal function through its receptors namely beta1 (cardiac output and renin release), alpha1 (systemic and renovascular constriction), and beta2 renovascular dilation. Sympathetic overactivity is commonly seen in chronic kidney disease (CKD) and is an important contributor to increasing the risk of cardiovascular events as well as increasing renal disease progression. Recent evaluations of drug use in people with CKD shows a remarkably low percentage of patients receiving beta-blockers, especially in more advanced stage CKD when cardiovascular risk is higher. This is in large part due to tolerability of these agents. Moreover, water-soluble beta-blockers such as atenolol and metoprolol are dialyzable and require supplementation to avoid exacerbation of arrhythmias following dialysis. Newer vasodilating beta-blockers have better tolerability and different effects on renal hemodynamics as well as metabolic variables. These effects are related to the relative alpha1-blocking effect of agents such as carvedilol and labetolol, with carvedilol having relatively greater alpha-blocking effects. Few studies evaluate beta-blockers on cardiovascular risk in CKD patients. Studies with carvedilol demonstrate attenuated increases in albuminuria as well as reduction in cardiovascular events in CKD patients with hypertension. This paper reviews the animal and clinical trial data that evaluate beta-blockers in CKD highlighting the vasodilating beta-blockers. It is apparent that greater use of this drug class for blood pressure control would further enhance reduction of risk of heart failure, the most common cause of death in the first year of starting dialysis.
交感神经系统通过其受体调节肾功能，这些受体包括β1（心输出量和肾素释放）、α1（全身和肾血管收缩）和β2（肾血管舒张）。交感神经活动亢进在慢性肾脏病（CKD）中常见，是心血管事件风险增加以及肾脏疾病进展的重要促成因素。最近对CKD患者用药情况的评估显示，接受β受体阻滞剂治疗的患者比例极低，尤其是在心血管风险较高的CKD晚期患者中。这在很大程度上归因于这些药物的耐受性。此外，水溶性β受体阻滞剂如阿替洛尔和美托洛尔可被透析清除，需要补充药物以避免透析后心律失常加重。新型血管舒张性β受体阻滞剂具有更好的耐受性，对肾血流动力学以及代谢变量有不同影响。这些作用与卡维地洛和拉贝洛尔等药物的相对α1阻滞作用有关，其中卡维地洛具有相对更强的α阻滞作用。很少有研究评估β受体阻滞剂对CKD患者心血管风险的影响。卡维地洛的研究表明，CKD高血压患者使用卡维地洛后蛋白尿增加减弱，心血管事件减少。本文综述了评估CKD患者使用β受体阻滞剂（重点是血管舒张性β受体阻滞剂）的动物和临床试验数据。显然，更多地使用这类药物控制血压将进一步降低心力衰竭风险，心力衰竭是开始透析后第一年最常见的死亡原因。
