Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, N.Y., USA.
Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, N.Y., USA ; National Kidney Foundation, Inc., New York, N.Y., USA.
Cardiorenal Med. 2014 Aug;4(2):113-22. doi: 10.1159/000363114. Epub 2014 Jun 4.
Despite the availability of blood pressure (BP)-lowering medications and dietary education, hypertension is still poorly controlled in the chronic kidney disease (CKD) population. As glomerular filtration rate declines, the number of medications required to achieve BP targets increases, which may lead to reduced patient adherence and therapeutic inertia by the clinician. Home BP monitoring (HBPM) has emerged as a means of improving diagnostic accuracy, risk stratification, patient adherence, and therapeutic intervention. The definition of hypertension by HBPM is an average BP >135/85 mm Hg. Twelve readings over the course of 3-5 days are sufficient for clinical decision making. Diagnostic accuracy is especially important in the CKD population as approximately half of these patients have either white coat hypertension or masked hypertension. Preliminary data suggest that HBPM outperforms office BP monitoring in predicting progression to end-stage renal disease or death. When combined with additional support such as telemonitoring, medication titration, or behavioral therapy, HBPM results in a sustained improvement in BP control. HBPM must be adapted to provide information on the phenomena of nondipping (absence of nocturnal fall in BP) and reverse dipping (paradoxical increase in BP at night). These diurnal patterns are more prevalent in the CKD population and are important cardiovascular risk factors. Ambulatory BP monitoring provides nocturnal BP readings and unlike HBPM may be reimbursed by Medicare when certain criteria are met. Further studies are needed to determine whether HBPM is cost-effective in the current US healthcare system.
尽管有降压药物和饮食教育可用，慢性肾脏病 (CKD) 患者的血压仍控制不佳。随着肾小球滤过率下降，达到血压目标所需的药物数量增加，这可能导致患者依从性降低和临床医生治疗惰性。家庭血压监测 (HBPM) 已成为提高诊断准确性、风险分层、患者依从性和治疗干预的一种手段。HBPM 定义的高血压是平均血压>135/85mmHg。在 3-5 天的时间内进行 12 次读数足以进行临床决策。在 CKD 患者中，诊断准确性尤为重要，因为这些患者中约有一半患有白大衣高血压或隐匿性高血压。初步数据表明，HBPM 在预测进展为终末期肾病或死亡方面优于诊室血压监测。当与远程监测、药物滴定或行为疗法等额外支持相结合时，HBPM 可使血压控制持续改善。HBPM 必须进行调整，以提供无夜间血压下降（夜间血压无下降）和反向夜间血压下降（夜间血压异常升高）现象的信息。这些昼夜模式在 CKD 患者中更为普遍，是重要的心血管危险因素。动态血压监测可提供夜间血压读数，与 HBPM 不同，当满足某些标准时，Medicare 可能会报销。需要进一步研究以确定在当前美国医疗保健系统中 HBPM 是否具有成本效益。
