Del Vecchio Lucia, Teatini Ugo, Locatelli Francesco
Department of Nephrology and Dialysis, A. Manzoni Hospital, ASST Lecco, Lecco, Italy.
Department of Nephrology and Dialysis, ASST Rhodense, Garbagnate Milanese, Milan, Italy.
Panminerva Med. 2017 Jun;59(2):166-172. doi: 10.23736/S0031-0808.17.03293-1. Epub 2017 Jan 13.
Elevated blood pressure is one of the most significant risk factor for the development of chronic kidney disease (CKD); its treatment is a milestone in CKD management. While it is accepted that a stricter blood pressure control is indicated in patients with proteinuria or microalbuminuria, the exact degree of blood pressure reduction to be obtained in CKD patients is still under debate. Following more recent interpretation of old trials, a BP target for <140/90 mmHg is suggested for non-proteinuric CKD patients. In those with microalbuminuria/proteinuria, the ideal blood pressure target should be ≤130/80 mmHg. Recently, the SPRINT trial put new emphasis on a stricter blood pressure control, mainly from the cardiovascular point of view. The blockers of the renin-angiotensin system (RAS) are recommended as first line treatment in all CKD hypertensive patients with micro or macroalbuminuria either diabetics or not. However, their nephroprotective efficacy is less relevant in non-proteinuric patients. The dual RAS blockade was proposed as an additional option. Despite a greater antiproteinuric effect, some large trials in patients at high cardiovascular risk did not demonstrate significant advantage on hard endpoint. Its use is now contraindicated in diabetic CKD patients. Given that RAS blockers can cause acute derangements in kidney function and hyperkalemia, caution is needed with their use, especially in frail and old patients with cardiovascular disease or in the presence of advanced CKD.
血压升高是慢性肾脏病（CKD）发生的最重要危险因素之一；其治疗是CKD管理中的一个里程碑。虽然人们公认蛋白尿或微量白蛋白尿患者需要更严格的血压控制，但CKD患者究竟应将血压降至何种程度仍存在争议。根据对既往试验的最新解读，建议非蛋白尿性CKD患者的血压目标为<140/90 mmHg。对于微量白蛋白尿/蛋白尿患者，理想的血压目标应为≤130/80 mmHg。最近，收缩压干预试验（SPRINT）主要从心血管角度对更严格的血压控制提出了新的重点。肾素-血管紧张素系统（RAS）阻滞剂被推荐作为所有伴有微量或大量白蛋白尿的CKD高血压患者（无论是否为糖尿病患者）的一线治疗药物。然而，它们在非蛋白尿患者中的肾脏保护作用较小。有人提出双重RAS阻断作为一种额外选择。尽管具有更大的抗蛋白尿作用，但一些针对心血管高危患者的大型试验并未显示在硬终点方面有显著优势。目前糖尿病CKD患者禁用。鉴于RAS阻滞剂可导致肾功能急性紊乱和高钾血症，使用时需要谨慎，尤其是在体弱和患有心血管疾病的老年患者或存在晚期CKD的患者中。
