Department of Internal Medicine, Hypertension and Vascular Diseases, Medical University of Warsaw, Warsaw, Poland.
Fresenius Medical Care, Poznań, Poland.
Kidney Blood Press Res. 2024;49(1):630-636. doi: 10.1159/000540285. Epub 2024 Jul 16.
The prevalence of hypertension among patients with end-stage kidney disease (ESKD) undergoing hemodialysis (HD) ranges from 72 to 88% depending on applied diagnostic criteria and the chosen method of blood pressure measurement. Despite the guidelines recommending the widespread use of renin-angiotensin system blockers (RASBs) in patients with kidney disease, their utilization in patients on HD may be suboptimal, especially in patients with preserved diuresis. This hesitance that often steams from concern is often due to fear of a decrease in eGFR and a subsequent decrease in diuresis. The aim of this study was to compare clinical characteristics, blood pressure, safety, and HD adequacy indices in hypertensive HD patients on multiple antihypertensive drug regimens, including diuretic treated with RASB (RASB group) or without RASB (no-RASB) with preserved residual diuresis. We sought to examine the real-life use of RASB in HD patients in relation to their clinical characteristics, blood pressure, safety, and HD adequacy.
From a database of 5,879 patients receiving HD (mean age 65.2 ± 14.2 years, 60% of males) of the largest provider of HD in the country, we selected the subgroup treated with at least three antihypertensive medications including diuretics. We compared patients treated with RASB to counterparts without RASB (no-RASB).
The RASB group has similar age and gender proportions as well as BMI and bioimpedance compared to counterparts. However, dry body mass was significantly lower in the RASB group (78.1 ± 18.3 kg vs. 80.0 ± 18.2 kg, p < 0.017). Prevalence of diabetes mellitus was similar in both groups, but RASB-treated patients have cardiovascular diseases more frequently (70.1 vs. 60.8%; p < 0.001). Systolic blood pressure and the number of antihypertensive drugs used were significantly higher in RASB patients than in counterparts (146 ± 16 mm Hg vs. 144 ± 15 mm Hg; p < 0.001 and 4.1 ± 0.9 vs. 3.5 ± 0.5; p < 0001, respectively). RASB-treated patients have significantly longer dialysis vintage (52.7 ± 44.4 months vs. 40.2 ± 40.9 months; p < 0.001) and dialysis time (722 ± 87.1 min/week vs. 713 ± 93.4 min/week; p < 0.017) than counterparts. Serum potassium was slightly but significantly higher in RASB (5.3 ± 0.8 mmol/L vs. 5.1 ± 0.7 mmol/L; p < 0.01).
In the real world setting, RASB can be safely used in HD patients treated with diuretics with preserved residual diuresis. Given that many HD patients present numerous multimorbidities, RASB should not only be considered as an additional hypotensive drug in poorly controlled hypertension but also in other compelling indications in HD patients. The tendency toward hyperkalemia in HD patients could be effectively managed with appropriate diet and HD prescription adjustments.
根据所应用的诊断标准和所选择的血压测量方法，接受血液透析（HD）的终末期肾病（ESKD）患者中高血压的患病率为 72%至 88%不等。尽管指南建议在有肾脏疾病的患者中广泛使用肾素-血管紧张素系统阻滞剂（RASB），但在接受 HD 的患者中，其使用可能并不理想，尤其是在保留利尿剂的患者中。这种犹豫往往源于对肾功能下降和随后利尿剂减少的担忧。本研究旨在比较高血压 HD 患者在使用多种降压药物治疗时的临床特征、血压、安全性和 HD 充分性指数，包括使用 RASB（RASB 组）或不使用 RASB（无 RASB 组）治疗利尿剂的患者，且保留残余利尿剂。我们旨在研究 RASB 在 HD 患者中的实际应用与他们的临床特征、血压、安全性和 HD 充分性的关系。
从全国最大的 HD 服务提供商的 5879 名接受 HD 治疗的患者（平均年龄 65.2 ± 14.2 岁，60%为男性）的数据库中，我们选择了接受至少三种包括利尿剂在内的降压药物治疗的亚组。我们比较了接受 RASB 治疗的患者与未接受 RASB 治疗的患者（无 RASB 组）。
RASB 组的年龄和性别比例以及 BMI 和生物阻抗与对照组相似。然而，RASB 组的干体重明显较低（78.1 ± 18.3 kg 与 80.0 ± 18.2 kg，p < 0.017）。两组的糖尿病患病率相似，但 RASB 治疗的患者更常患有心血管疾病（70.1%比 60.8%；p < 0.001）。RASB 治疗的患者的收缩压和使用的降压药物数量明显高于对照组（146 ± 16 mm Hg 比 144 ± 15 mm Hg；p < 0.001 和 4.1 ± 0.9 比 3.5 ± 0.5；p < 0001，分别）。RASB 治疗的患者的透析龄（52.7 ± 44.4 个月比 40.2 ± 40.9 个月；p < 0.001）和透析时间（722 ± 87.1 min/周比 713 ± 93.4 min/周；p < 0.017）明显长于对照组。RASB 组的血清钾稍高但有统计学意义（5.3 ± 0.8 mmol/L 比 5.1 ± 0.7 mmol/L；p < 0.01）。
在真实世界环境中，RASB 可安全用于接受利尿剂治疗且保留残余利尿剂的 HD 患者。鉴于许多 HD 患者存在多种合并症，RASB 不仅应被视为血压控制不佳的高血压患者的附加降压药物，也应被视为 HD 患者的其他适应证。HD 患者的高钾血症倾向可以通过适当的饮食和 HD 处方调整来有效管理。
