血壓目標可能與白蛋白尿無關


  【24drs.com】新研究認為,在中度到惡化慢性腎病(chronic kidney disease,CKD)患者中,收縮壓升高與腎功能快速衰退有關,不論有無白蛋白尿。
  
  英國牛津大學臨床試驗服務小組流行病學研究小組的Natalie Staplin博士表示,目前有關CKD患者的血壓處置指引建議,沒有白蛋白尿者的目標值高於有白蛋白尿者。
  
  她解釋,我們的研究結果認為,使用白蛋白尿值決定CKD患者的血壓目標並不適當;不過,她承認,需要用更大型的研究比較密集化與標準化降血壓的方式才能確認研究結果。
  
  Staplin博士在2015年腎臟週:美國腎臟科協會年會中發表研究結果。
  
  這篇研究包括了納入「Study of Heart and Renal Protection (SHARP)」試驗的CKD患者資料,該試驗證實,CKD患者使用以statin類製劑為主的處方降低低密度脂蛋白膽固醇值時,心肌梗塞或中風風險降低。
  
  在他們的分析中,Staplin博士等人針對尿中白蛋白值不同的患者,檢視了收縮壓和估計腎絲球過濾速率(eGFR)的關聯。
  
  研究開始時,6,000名患者中有20%的eGFR低於15 mL/minute/1.73 m2,40%的eGFR介於15-30 mL/minute/1.73 m2,40%的eGFR介於30-60 mL/minute/1.73 m2。
  
  Staplin博士報告指出,在我們的分析中,我們採用長期平均收縮壓,目的是希望不要低估收縮壓對於末期腎病惡化的影響。
  
  校正有無出現白蛋白尿之前,收縮壓每升高10 mm Hg,末期腎病風險增加32%。(風險比[HR]為1.32;95%信賴區間[CI]為1.23 - 1.41)。
  
  校正白蛋白尿情況之後,風險降低到10%,但依舊顯著(HR, 1.1;95% CI, 1.03 - 1.18)。
  
  Staplin博士表示,對於白蛋白尿值高的患者,收縮壓每升高20mm Hg,與每年eGFR平均降低超過0.7 mL/min/1.73 m2有關。
  
  白蛋白尿值低的患者以及沒有白蛋白尿者,每年的eGFR衰退程度相當,為0.6 mL/minute/1.73 m2。
  
  難以確認高血壓是否是腎病惡化的原因,也難以確認是否因為腎病惡化導致血壓不易控制。
  
  會議共同主持人、南卡羅來納Dialysis Clinic公司的Milos Budisavjevic表示,不過,SHARP研究資料明確地顯示,血壓控制較佳可以延緩eGFR的惡化,不論有無出現白蛋白尿。
  
  他表示,我認為SHARP研究提出很重要的資料,事實上,血壓是我們對CKD患者在延緩腎病惡化方面,唯一能控制的因素。
  
  這是唯一有用的方法,這篇試驗提供良好證據指出,我們可以藉由適當控制收縮壓而延緩腎病惡化,不論有無出現白蛋白尿,良好的血壓控制都會有所幫助。
  
  資料來源:http://www.24drs.com/
  
  Native link:Blood Pressure Targets May Be Independent of Albuminuria

Blood Pressure Targets May Be Independent of Albuminuria

By Pam Harrison
Medscape Medical News

SAN DIEGO — In patients with moderate to advanced chronic kidney disease (CKD), elevated systolic blood pressure is associated with a rapid decline in renal function, regardless of the presence or absence of albuminuria, new research suggests.

"Current guidelines for the management of blood pressure in patients with CKD recommend higher targets for patients without albuminuria than for those with albuminuria," said Natalie Staplin, PhD, from the Clinical Trial Service Unit and Epidemiological Studies Unit at Oxford University in the United Kingdom.

"Our findings suggest that using levels of albuminuria to decide on blood pressure targets in CKD may not be appropriate," she explained. However, she acknowledged that the results need to be confirmed in a large trial comparing intensive and standard blood pressure lowering.

Dr Staplin presented the results here at Kidney Week 2015: American Society of Nephrology Annual Meeting.

The study involved data from patients with CKD enrolled in the Study of Heart and Renal Protection (SHARP) trial. That trial established that the risk for myocardial infarction or stroke in patients with CKD was decreased when a statin-based regimen was used to lower levels of low-density lipoprotein cholesterol.

In their analysis, Dr Staplin and colleagues examined the association between systolic blood pressure and estimated glomerular filtration rate (eGFR) in patients with different levels of albuminuria in the urine.

At baseline, 20% of the 6000 patients had an eGFR below 15 mL/minute per 1.73 m2, 40% had an eGFR of 15 to 30 mL/minute per 1.73 m2, and 40% had an eGFR of 30 to 60 mL/minute per 1.73 m2.

"In our analysis, we used exposure of the long-term average systolic blood pressure so as not to underestimate the effects of systolic blood pressure on progression to end-stage renal disease," Dr Staplin reported.

Before adjustment for the presence of albuminuria, there was a 32% increase in the risk for end-stage renal disease with every 10 mm Hg increase in systolic blood pressure (hazard ratio [HR], 1.32; 95% confidence interval [CI], 1.23 - 1.41).

After adjustment for the presence of albuminuria, that risk decreased to 10%, although it remained significant (HR, 1.1; 95% CI, 1.03 - 1.18).

"For patients with high levels of albuminuria, each 20 mm Hg increase in systolic blood pressure was associated with a mean greater decline in eGFR of 0.7 mL/min per 1.73 m2 per year," Dr Staplin told Medscape Medical News.

In patients with low levels of albuminuria, and in those with no detectable albuminuria, the annual decline in eGFR was similar, at 0.6 mL/minute per 1.73 m2.

The SHARP study showed us very important data because, in fact, blood pressure is really the only thing we can control in patients with CKD to slow kidney disease progression. Dr Milos Budisavjevic

It is difficult to determine whether high blood pressure is the cause of renal disease progression, or whether progression of renal disease makes it more difficult to control blood pressure.

However, the SHARP data unequivocally showed that better blood pressure control can slow down the deterioration in eGFR in the absence and in the presence of albuminuria, said session cochair Milos Budisavjevic, MD, from Dialysis Clinic Inc in Charleston, South Carolina.

"I think the SHARP study showed us very important data because, in fact, blood pressure is really the only thing we can control in patients with CKD to slow kidney disease progression," he told Medscape Medical News.

"It's the only thing that works," he added. "This trial has provided us with good evidence that we can slow progression of kidney disease by optimally controlling systolic blood pressure, and that good blood pressure control works independently of albuminuria."

The study was supported by a grant from Merck/Schering-Plough Pharmaceuticals.

Kidney Week 2015: American Society of Nephrology Annual Meeting: Abstract TH-OR020. Presented November 5, 2015.

    
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