Kim In Soo, Kim Sungmin, Yoo Tae-Hyun, Kim Jwa-Kyung
Department of Internal Medicine & Kidney Research Institute, Hallym University Sacred Heart Hospital, Pyungan-dong, Dongan-gu, Anyang, 431-070, Korea.
Department of Internal Medicine, College of Medicine, Institute of Kidney Disease Research, Yonsei University, Seoul, Korea.
Clin Hypertens. 2023 Sep 1;29(1):24. doi: 10.1186/s40885-023-00240-x.
In patients with end-stage renal disease (ESRD) undergoing dialysis, hypertension is common but often inadequately controlled. The prevalence of hypertension varies widely among studies because of differences in the definition of hypertension and the methods of used to measure blood pressure (BP), i.e., peri-dialysis or ambulatory BP monitoring (ABPM). Recently, ABPM has become the gold standard for diagnosing hypertension in dialysis patients. Home BP monitoring can also be a good alternative to ABPM, emphasizing BP measurement outside the hemodialysis (HD) unit. One thing for sure is pre- and post-dialysis BP measurements should not be used alone to diagnose and manage hypertension in dialysis patients. The exact target of BP and the relationship between BP and all-cause mortality or cause-specific mortality are unclear in this population. Many observational studies with HD cohorts have almost universally reported a U-shaped or even an L-shaped association between BP and all-cause mortality, but most of these data are based on the BP measured in HD units. Some data with ABPM have shown a linear association between BP and mortality even in HD patients, similar to the general population. Supporting this, the results of meta-analysis have shown a clear benefit of BP reduction in HD patients. Therefore, further research is needed to determine the optimal target BP in the dialysis population, and for now, an individualized approach is appropriate, with particular emphasis on avoiding excessively low BP. Maintaining euvolemia is of paramount importance for BP control in dialysis patients. Patient heterogeneity and the lack of comparative evidence preclude the recommendation of one class of medication over another for all patients. Recently, however, β-blockers could be considered as a first-line therapy in dialysis patients, as they can reduce sympathetic overactivity and left ventricular hypertrophy, which contribute to the high incidence of arrhythmias and sudden cardiac death. Several studies with mineralocorticoid receptor antagonists have also reported promising results in reducing mortality in dialysis patients. However, safety issues such as hyperkalemia or hypotension should be further evaluated before their use.
在接受透析的终末期肾病（ESRD）患者中，高血压很常见，但往往控制不佳。由于高血压定义和血压测量方法（即透析期间或动态血压监测[ABPM]）的差异，不同研究中高血压的患病率差异很大。近年来，ABPM已成为诊断透析患者高血压的金标准。家庭血压监测也可作为ABPM的良好替代方法，强调在血液透析（HD）单元之外测量血压。可以确定的是，透析前和透析后的血压测量不应单独用于诊断和管理透析患者的高血压。该人群中血压的确切目标以及血压与全因死亡率或特定病因死亡率之间的关系尚不清楚。许多针对HD队列的观察性研究几乎普遍报告了血压与全因死亡率之间呈U形甚至L形关联，但这些数据大多基于在HD单元测量的血压。一些ABPM数据显示，即使在HD患者中，血压与死亡率之间也呈线性关联，与普通人群相似。支持这一点的是，荟萃分析结果表明降低HD患者血压有明显益处。因此，需要进一步研究以确定透析人群的最佳血压目标，目前，采用个体化方法是合适的，尤其要强调避免血压过低。维持血容量正常对于透析患者的血压控制至关重要。患者的异质性以及缺乏比较证据使得无法为所有患者推荐某一类药物优于另一类药物。然而，近年来，β受体阻滞剂可被视为透析患者的一线治疗药物，因为它们可以减少交感神经过度活跃和左心室肥厚，而这两者会导致心律失常和心源性猝死的高发生率。几项使用盐皮质激素受体拮抗剂的研究也报告了在降低透析患者死亡率方面的有前景的结果。然而，在使用前应进一步评估高钾血症或低血压等安全性问题。
