Zheng Sijie, Nath Vijay, Coyne Daniel W
Department of Internal Medicine, Renal Division, Chromalloy American Kidney Center and Washington University School of Medicine, Saint Louis, MO 61110, USA.
Am J Nephrol. 2007;27(5):522-9. doi: 10.1159/000107490. Epub 2007 Aug 16.
Hypertension is present in nearly 80% of dialysis patients yet adequately controlled in less than half. We designed a stepped antihypertensive regimen using long-acting antihypertensives (trandolapril, atenolol and amlodipine) administered thrice a week (TIW) after each hemodialysis, and compared blood pressure (BP) control, medication cost and pill burden to each patient's prior daily antihypertensive prescriptions.
Patients were continued on their daily medications, pre-dialysis sitting BP was measured and a 44-hour interdialytic ambulatory BP monitoring (ABPM) was obtained. Then, their medications were stopped and replaced with trandolapril (2 mg TIW). Atenolol and/or amlodipine were also given TIW if the patients had any member of these classes of drugs as part of their daily regimen. Medications were titrated every 2 weeks to achieve a pre-dialysis mean arterial pressure (MAP) of <107 mm Hg. After 2 consecutive weeks with a pre-dialysis MAP of <107 mm Hg, a second 44-hour ABPM was obtained.
Ten patients completed the study. A persistent MAP of <107 was maintained in all 10 patients after conversion to TIW dosing. The systolic BP decreased from 122.2 +/- 7.1 to 116.4 +/- 11.6, and the diastolic BP decreased from 75.3 +/- 10.4 to 70.4 +/- 11.4 mm Hg. Pill burden and cost of medications were also significantly less.
This pilot study found that ACE inhibitor-based, directly observed TIW therapy to be effective in hemodialysis patients with mild to moderate hypertension. Larger trials of directly observed therapy for hypertension in dialysis patients are warranted.
近80%的透析患者患有高血压，但血压得到充分控制的患者不到一半。我们设计了一种阶梯式降压方案，使用长效抗高血压药物（群多普利、阿替洛尔和氨氯地平），在每次血液透析后每周给药三次（TIW），并将血压（BP）控制情况、药物成本和药丸负担与每位患者之前的每日抗高血压处方进行比较。
患者继续服用日常药物，测量透析前坐位血压，并进行44小时透析间期动态血压监测（ABPM）。然后，停用他们的药物，换用群多普利（2 mg TIW）。如果患者日常用药中有这些类别的药物，也给予阿替洛尔和/或氨氯地平TIW。每2周调整一次药物剂量，以使透析前平均动脉压（MAP）<107 mmHg。在连续2周透析前MAP<107 mmHg后，再次进行44小时ABPM。
10名患者完成了研究。转换为TIW给药后，所有10名患者均维持了持续的MAP<107。收缩压从122.2±7.1降至116.4±11.6，舒张压从75.3±10.4降至70.4±11.4 mmHg。药丸负担和药物成本也显著降低。
这项初步研究发现，基于ACE抑制剂的、直接观察的TIW疗法对轻度至中度高血压的血液透析患者有效。有必要对透析患者高血压的直接观察疗法进行更大规模的试验。
