Segall Liviu, Oprisiu Roxana, Fournier Albert, Covic Adrian
Nephrology, Dialysis and Renal Transplantation Center, C.I. Parhon University Hospital, Iasi, Romania.
J Nephrol. 2008 May-Jun;21(3):374-83.
Stroke is the leading cause of serious long-term disability and the third leading cause of death in the Western world. In patients with chronic kidney disease (CKD), stroke and vascular dementia are significantly more prevalent than in the general population. However, the optimal stroke prevention strategy in these patients is unclear, because controlled studies are scarce.
In this paper, the results of the major antihypertensive trials and meta-analyses for stroke prevention in the general high cardiovascular (CV) risk population and in the CKD population are reviewed.
The risk of stroke is much more blood pressure (BP)-dependent than the risk of other CV events, and, consistently, risk reduction is also strongly dependent on BP reduction. The magnitude of BP lowering is crucial in both populations. In renal patients, diuretics alone or in combination with angiotensin-converting enzyme (ACE) inhibitors, compared with placebo, are powerful BP-lowering and stroke-protective agents. Calcium channel blockers and ACE inhibitors also seem to be superior to placebo, but with more modest BP-decreasing effects and statistically nonsignificant reductions in stroke risk. In active versus active drug studies, independently of the BP-lowering effect, there are no significant advantages of any class over the others, although the results point to a slight superiority of diuretics and calcium channel blockers. Antihypertensive regimens in CKD patients should always include a diuretic, because, in the pathogenesis of CKD-associated hypertension, volume overload plays a crucial role. Diuretics are also inexpensive and well tolerated.
We suggest that further studies of CV outcomes in CKD patients should compare various combinations of diuretics plus other drugs, such as calcium channel blockers, ACE inhibitors and angiotensin II receptor blockers.
中风是导致严重长期残疾的主要原因，也是西方世界第三大死因。在慢性肾脏病（CKD）患者中，中风和血管性痴呆的患病率明显高于普通人群。然而，由于对照研究稀缺，这些患者的最佳中风预防策略尚不清楚。
本文回顾了主要抗高血压试验以及针对一般心血管（CV）高风险人群和CKD人群中风预防的荟萃分析结果。
中风风险比其他CV事件风险更依赖于血压（BP），同样，风险降低也强烈依赖于血压降低。血压降低的幅度在这两个人群中都至关重要。在肾病患者中，与安慰剂相比，单独使用利尿剂或与血管紧张素转换酶（ACE）抑制剂联合使用都是强大的降压和预防中风药物。钙通道阻滞剂和ACE抑制剂似乎也优于安慰剂，但降压效果更温和，中风风险降低在统计学上不显著。在活性药物与活性药物的研究中，尽管结果表明利尿剂和钙通道阻滞剂略有优势，但与降压效果无关，任何一类药物都没有比其他药物有显著优势。CKD患者的抗高血压治疗方案应始终包括利尿剂，因为在CKD相关高血压的发病机制中，容量超负荷起着关键作用。利尿剂也价格低廉且耐受性良好。
我们建议，对CKD患者的心血管结局进行进一步研究时，应比较利尿剂与其他药物（如钙通道阻滞剂、ACE抑制剂和血管紧张素II受体阻滞剂）的各种组合。
