Agarwal Rajiv, Sinha Arjun D
Indiana University School of Medicine and Richard L. Roudebush Veterans Administration Medical Center, Indianapolis, IN 46202, USA.
J Am Soc Hypertens. 2012 Sep-Oct;6(5):299-308. doi: 10.1016/j.jash.2012.07.004. Epub 2012 Aug 28.
Chronic kidney disease (CKD) is prevalent in 3%-4% of the adult population in the United States, and the vast majority of these people are hypertensive. Compared with those with essential hypertension, hypertension in CKD remains poorly controlled despite the use of multiple antihypertensive drugs. Hypervolemia is thought to be a major cause of hypertension, and diuretics are useful to improve blood pressure control in CKD. Non-osmotic storage of sodium in the skin and muscle may be a novel mechanism by which sodium may modulate hypertension; further work is need to study this novel phenomenon with diuretics. Among people with stage 4 CKD, loop diuretics are recommended over thiazides. Thiazide diuretics are deemed ineffective in people with stage 4 CKD. Review of the literature suggests that thiazides may be useful even among people with advanced CKD. They cause a negative sodium balance, increasing sodium excretion by 10%-15% and weight loss by 1-2 kg in observational studies. Observational data show improvement in seated clinic blood pressure of about 10-15 mm Hg systolic and 5-10 mm Hg diastolic, whereas randomized trials show about 15 mm Hg improvement in mean arterial pressure. Volume depletion, hyponatremia, hypokalemia, hypercalcemia, and acute kidney injury are adverse effects that should be closely monitored. Our review suggests that adequately powered randomized trials are needed before the use of thiazide diuretics can be firmly recommended in those with advanced CKD.
慢性肾脏病（CKD）在美国3%-4%的成年人口中普遍存在，而且这些人绝大多数患有高血压。与原发性高血压患者相比，尽管使用了多种抗高血压药物，但CKD患者的高血压仍控制不佳。血容量过多被认为是高血压的主要原因，利尿剂有助于改善CKD患者的血压控制。皮肤和肌肉中钠的非渗透性储存可能是钠调节高血压的一种新机制；需要进一步开展研究以通过利尿剂来研究这一新现象。在4期CKD患者中，推荐使用襻利尿剂而非噻嗪类利尿剂。噻嗪类利尿剂被认为对4期CKD患者无效。文献综述表明，即使在晚期CKD患者中，噻嗪类利尿剂可能也有用。在观察性研究中，它们会导致负钠平衡，使钠排泄增加10%-15%，体重减轻1-2千克。观察性数据显示，坐位诊室收缩压改善约10-15 mmHg，舒张压改善5-10 mmHg，而随机试验显示平均动脉压改善约15 mmHg。血容量减少、低钠血症、低钾血症、高钙血症和急性肾损伤是应密切监测的不良反应。我们的综述表明，在能够明确推荐晚期CKD患者使用噻嗪类利尿剂之前，需要开展足够有力的随机试验。
