Foley Robert N, Agarwal Rajiv
Chronic Disease Research Group and University of Minnesota, Minneapolis, Minnesota, USA.
Semin Dial. 2007 Nov-Dec;20(6):518-22. doi: 10.1111/j.1525-139X.2007.00337.x.
Managing hypertension is among the commonest and most challenging features of end-stage renal disease and many clinical trials have shown the benefit of treating hypertension in the general population. If associations between blood pressure levels and cardiovascular outcomes in dialysis patients mirrored those seen in general population studies, one could argue that dialysis population-specific antihypertensive trials are unnecessary. Associations between blood pressure levels and outcomes are complex in this population. Naturally, comparisons of observational and experimental findings within intervention in patients with chronic kidney disease often show a surprising degree of disparity. In addition, the possibility of serious unmeasured co-morbid illnesses masking the true causal relationship between blood pressure and outcomes in this population looms large. Unfortunately, therefore, observational studies appear to be highly unreliable guides to identifying the truth regarding optimal management of hypertension. It appears, then, that controlled trials, alone, can inform appropriate treatment. Of late, intervention trials of antihypertensives in dialysis patients have begun to emerge. Though mostly small, less than definitive, and heterogeneous regarding patient selection, interventions and outcomes, several suggest net benefit and none suggests net harm. As dialysis patients are at vast cardiovascular risk, these findings suggest that aggressive treatment of hypertension should be the default approach, until large clinical trials show otherwise.
管理高血压是终末期肾病最常见且最具挑战性的问题之一,许多临床试验已表明在普通人群中治疗高血压的益处。如果透析患者的血压水平与心血管结局之间的关联反映了普通人群研究中的情况,那么有人可能会认为针对透析人群的特定抗高血压试验是不必要的。在这一人群中,血压水平与结局之间的关联很复杂。自然地,对慢性肾病患者进行干预时观察性研究结果与实验性研究结果的比较往往显示出惊人的差异程度。此外,严重的未测量合并症掩盖该人群中血压与结局之间真正因果关系的可能性很大。因此,不幸的是,观察性研究似乎是确定高血压最佳管理方法真相的极不可靠的指南。那么,似乎只有对照试验才能为适当的治疗提供依据。最近,针对透析患者的抗高血压干预试验已开始出现。尽管大多规模较小、不够明确,且在患者选择、干预措施和结局方面存在异质性,但有几项试验显示出净益处,且没有一项试验显示出净危害。由于透析患者面临巨大的心血管风险,这些发现表明,在大型临床试验证明并非如此之前,积极治疗高血压应作为默认方法。