Peterson J C, Adler S, Burkart J M, Greene T, Hebert L A, Hunsicker L G, King A J, Klahr S, Massry S G, Seifter J L
Ann Intern Med. 1995 Nov 15;123(10):754-62. doi: 10.7326/0003-4819-123-10-199511150-00003.
To examine the relations among proteinuria, prescribed and achieved blood pressure, and decline in glomerular filtration rate in the Modification of Diet in Renal Disease Study.
2 randomized trials in patients with chronic renal diseases of diverse cause.
15 outpatient nephrology practices at university hospitals.
840 patients, of whom 585 were in study A (glomerular filtration rate, 25 to 55 mliters/min.1.73 m2) and 255 were in study B (glomerular filtration rate, 13 to 24 mliters/min.1.73 m2). Diabetic patients who required insulin were excluded.
Patients were randomly assigned to a usual blood pressure goal (target mean arterial pressure, < or = 107 mm Hg for patients < or = 60 years of age and < or = 113 mm Hg for patients > or = 61 years of age) or a low blood pressure goal (target mean arterial pressure, < or = 92 mm Hg for patients < or = 60 years of age and < or = 98 mm Hg for patients > or = 61 years of age).
Rate of decline in glomerular filtration rate and change in proteinuria during follow-up.
The low blood pressure goal had a greater beneficial effect in persons with higher baseline proteinuria in both study A (P = 0.02) and study B (P = 0.01). Glomerular filtration rate declined faster in patients with higher achieved blood pressure during follow-up in both study A (r = -0.20; P < 0.001) and study B (r = -0.34; P < 0.001), and these correlations were stronger in persons with higher baseline proteinuria (P < 0.001 in study A; P < 0.01 in study B). In study A, the association between decline in glomerular filtration rate and achieved follow-up blood pressure was nonlinear (P = 0.011) and was stronger at higher mean arterial pressure. In both studies, the low blood pressure goal significantly reduced proteinuria during the first 4 months after randomization. This, in turn, correlated with a slower subsequent decline in glomerular filtration rate.
Our study supports the concept that proteinuria is an independent risk factor for the progression of renal disease. For patients with proteinuria of more than 1 g/d, we suggest a target blood pressure of less than 92 mm Hg (125/75 mm Hg). For patients with proteinuria of 0.25 to 1.0 g/d, a target mean arterial pressure of less than 98 mm Hg (about 130/80 mm Hg) may be advisable. The extent to which lowering blood pressure reduces proteinuria may be a measure of the effectiveness of this therapy in slowing the progression of renal disease.
在肾脏病饮食改良研究中，探讨蛋白尿、规定血压与实际血压以及肾小球滤过率下降之间的关系。
针对病因各异的慢性肾病患者进行的2项随机试验。
大学医院的15个门诊肾病科。
840例患者，其中585例纳入研究A（肾小球滤过率为25至55毫升/分钟·1.73平方米），255例纳入研究B（肾小球滤过率为13至24毫升/分钟·1.73平方米）。排除需要胰岛素治疗的糖尿病患者。
患者被随机分配至常规血压目标组（目标平均动脉压，60岁及以下患者≤107毫米汞柱，61岁及以上患者≤113毫米汞柱）或低血压目标组（目标平均动脉压，60岁及以下患者≤92毫米汞柱，61岁及以上患者≤98毫米汞柱）。
随访期间肾小球滤过率的下降速率及蛋白尿的变化。
在研究A（P = 0.02）和研究B（P = 0.01）中，低血压目标对基线蛋白尿水平较高的患者具有更大的有益作用。在研究A（r = -0.20；P < 0.001）和研究B（r = -0.34；P < 0.001）中，随访期间实际血压较高的患者肾小球滤过率下降更快，且这些相关性在基线蛋白尿水平较高的患者中更强（研究A中P < 0.001；研究B中P < 0.01）。在研究A中，肾小球滤过率下降与随访时达到的血压之间的关联是非线性的（P = 0.011），且在较高平均动脉压时更强。在两项研究中，低血压目标在随机分组后的前4个月均显著降低了蛋白尿。这反过来又与随后肾小球滤过率下降较慢相关。
我们的研究支持蛋白尿是肾病进展的独立危险因素这一概念。对于蛋白尿超过1克/天的患者，我们建议目标血压低于92毫米汞柱（125/75毫米汞柱）。对于蛋白尿为0.25至1.0克/天的患者，目标平均动脉压低于98毫米汞柱（约130/80毫米汞柱）可能是合适的。降低血压减少蛋白尿的程度可能是该疗法延缓肾病进展有效性的一个指标。
