Sarafidis Pantelis A, Khosla Nitin, Bakris George L
Hypertension/Clinical Research Center, Department of Preventive Medicine, Rush University Medical Center, Chicago, IL, USA.
Am J Kidney Dis. 2007 Jan;49(1):12-26. doi: 10.1053/j.ajkd.2006.10.014.
The presence of proteinuria is a well-known risk factor for both the progression of renal disease and cardiovascular morbidity and mortality, and decreases in urine protein excretion level were associated with a slower decrease in renal function and decrease in risk of cardiovascular events. Increased blood pressure has a major role in the development of proteinuria in patients with either diabetic or nondiabetic kidney disease, and all recent guidelines recommend a blood pressure goal less than 130/80 mm Hg in patients with proteinuria to achieve maximal renal and cardiovascular protection. Drugs interfering with the renin-angiotensin system, ie, angiotensin-converting enzyme inhibitors and angiotensin receptor blockers, should be used as first-line antihypertensive therapy in patients with proteinuria because they seem to have a blood pressure-independent antiproteinuric effect, and if blood pressure levels are still out of goal, a diuretic should be added to this regimen. A combination of an angiotensin-converting enzyme inhibitor with an angiotensin receptor blocker or other classes of medications shown to decrease protein excretion, such as nondihydropyridine calcium antagonists or aldosterone receptor blockers, should be considered to decrease proteinuria further. This review provides an extended summary of current evidence regarding the associations of blood pressure with proteinuria, the rationale for currently recommended blood pressure goals, and the use of various classes of antihypertensive agents in proteinuric patients.
蛋白尿的存在是肾病进展以及心血管疾病发病率和死亡率的一个众所周知的危险因素，尿蛋白排泄水平的降低与肾功能下降减缓及心血管事件风险降低相关。血压升高在糖尿病或非糖尿病肾病患者蛋白尿的发生中起主要作用，并且所有近期指南都建议蛋白尿患者的血压目标应低于130/80 mmHg，以实现最大程度的肾脏和心血管保护。干扰肾素-血管紧张素系统的药物，即血管紧张素转换酶抑制剂和血管紧张素受体阻滞剂，应作为蛋白尿患者的一线降压治疗药物，因为它们似乎具有不依赖血压的抗蛋白尿作用，如果血压水平仍未达标，则应在该治疗方案中加用利尿剂。应考虑将血管紧张素转换酶抑制剂与血管紧张素受体阻滞剂或其他已显示可降低蛋白排泄的药物类别（如非二氢吡啶类钙拮抗剂或醛固酮受体阻滞剂）联合使用，以进一步降低蛋白尿。本综述对当前有关血压与蛋白尿关联的证据、当前推荐血压目标的理论依据以及各类抗高血压药物在蛋白尿患者中的应用进行了扩展总结。
