Georgianos Panagiotis I, Agarwal Rajiv
2nd Department of Nephrology, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece.
Division of Nephrology, Department of Medicine, Richard L. Roudebush Veterans Administration Medical Center, Indianapolis, Indiana.
J Am Soc Nephrol. 2024 Apr 1;35(4):505-514. doi: 10.1681/ASN.0000000000000315. Epub 2024 Jan 16.
Apparent treatment-resistant hypertension is defined as an elevated BP despite the use of ≥3 antihypertensive medications from different classes or the use of ≥4 antihypertensives regardless of BP levels. Among patients receiving maintenance hemodialysis or peritoneal dialysis, using this definition, the prevalence of apparent treatment-resistant hypertension is estimated to be between 18% and 42%. Owing to the lack of a rigorous assessment of some common causes of pseudoresistance, the burden of true resistant hypertension in the dialysis population remains unknown. What distinguishes apparent treatment-resistance from true resistance is white-coat hypertension and adherence to medications. Accordingly, the diagnostic workup of a dialysis patient with apparent treatment-resistant hypertension on dialysis includes the accurate determination of BP control status with the use of home or ambulatory BP monitoring and exclusion of nonadherence to the prescribed antihypertensive regimen. In a patient on dialysis with inadequately controlled BP, despite adherence to therapy with maximally tolerated doses of a β -blocker, a long-acting dihydropyridine calcium channel blocker, and a renin-angiotensin system inhibitor, volume-mediated hypertension is the most important treatable cause of resistance. In daily clinical practice, such patients are often managed with intensification of antihypertensive therapy. However, this therapeutic strategy is likely to fail if volume overload is not adequately recognized or treated. Instead of increasing the number of prescribed BP-lowering medications, we recommend diet and dialysate restricted in sodium to facilitate achievement of dry weight. The achievement of dry weight is facilitated by an adequate time on dialysis of at least 4 hours for delivering an adequate dialysis dose. In this article, we review the epidemiology, diagnosis, and management of resistant hypertension among patients on dialysis.
顽固性高血压的定义为尽管使用了≥3种不同类型的抗高血压药物或≥4种抗高血压药物（无论血压水平如何），血压仍持续升高。在接受维持性血液透析或腹膜透析的患者中，根据这一定义，顽固性高血压的患病率估计在18%至42%之间。由于缺乏对一些假性耐药常见原因的严格评估，透析人群中真正耐药高血压的负担仍不清楚。导致表面治疗抵抗与真正抵抗的区别在于白大衣高血压和药物依从性。因此，对透析时出现顽固性高血压的透析患者进行诊断检查，包括使用家庭或动态血压监测准确确定血压控制情况，并排除不依从规定的抗高血压治疗方案的情况。对于透析患者，尽管坚持使用最大耐受剂量的β受体阻滞剂、长效二氢吡啶类钙通道阻滞剂和肾素-血管紧张素系统抑制剂进行治疗，但血压仍控制不佳，容量介导的高血压是最重要的可治疗的耐药原因。在日常临床实践中，这类患者通常通过强化抗高血压治疗来管理。然而，如果容量超负荷未得到充分认识或治疗，这种治疗策略可能会失败。我们建议限制饮食和透析液中的钠含量，以促进达到干体重，而不是增加处方降压药的数量。通过至少4小时的充分透析时间以提供足够的透析剂量，有助于实现干体重。在本文中，我们回顾了透析患者中耐药高血压的流行病学、诊断和管理。
