Jo Wonji, Koh Eun Sil, Chung Sungjin
Division of Nephrology, Department of Internal Medicine, Yeouido St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
Clin Hypertens. 2023 May 15;29(1):14. doi: 10.1186/s40885-023-00238-5.
Fluid overload secondary to loss of functional nephron mass can elevate blood pressure, which is characteristic of hypertension shown in chronic kidney disease (CKD). Therefore, it is logical to use diuretics at appropriate dose to lower blood pressure in patients with CKD and hypertension. Despite the theoretical background on the use of diuretics in CKD, there have been no definitive data on the effectiveness or safety of diuretics as first-line therapy for the management of hypertension in patients with CKD. Results from some clinical trials have demonstrated that diuretics would not lower blood pressure. They could even worsen electrolyte imbalance and kidney function when they are administered in patients with CKD. Major clinical practice guidelines on management of blood pressure or CKD have stated that evidence for benefits of thiazide diuretics is not conclusive yet in patients with advanced CKD, although loop diuretics are often effective for volume control at lower glomerular filtration rate. Recently, evidence for diuretics as effective blood pressure lowering agents in patients with advanced CKD is increasing. Renoprotective effect of thiazide or loop diuretics might represent a consequence of their influence on blood pressure or their ability to potentiate the effect of renin-angiotensin system blockade by making intraglomerular pressure more renin-angiotensin system-dependent, although their direct benefit on renal function remains controversial. This review summarizes recent data on the possible role of diuretics in lowering blood pressure, slowing the progression of kidney disease, and reducing cardiovascular risk in CKD patients.
功能性肾单位数量减少继发的液体超负荷可使血压升高，这是慢性肾脏病（CKD）中高血压的特征。因此，对CKD合并高血压患者使用适当剂量的利尿剂来降低血压是合理的。尽管有关于在CKD中使用利尿剂的理论背景，但尚无关于利尿剂作为CKD患者高血压一线治疗有效性或安全性的确切数据。一些临床试验结果表明，利尿剂不会降低血压。在CKD患者中使用时，它们甚至会加重电解质失衡和肾功能损害。主要的血压管理或CKD临床实践指南指出，噻嗪类利尿剂对晚期CKD患者有益的证据尚不确凿，尽管袢利尿剂在较低肾小球滤过率时通常对容量控制有效。最近，有越来越多的证据表明利尿剂对晚期CKD患者是有效的降压药物。噻嗪类或袢利尿剂的肾脏保护作用可能是其对血压影响的结果，或者是通过使肾小球内压力更依赖肾素-血管紧张素系统来增强肾素-血管紧张素系统阻滞剂作用的能力，尽管它们对肾功能的直接益处仍存在争议。本综述总结了关于利尿剂在降低CKD患者血压、减缓肾病进展和降低心血管风险方面可能作用的最新数据。
