Reduction Of Cardiovascular Complications in Hypertensive Patients With Chronic Kidney Disease

Cardiovascular disease (CVD) is the main cause of death in patients with chronic kidney disease (CKD), accounting for about 50 percent of patients with end-stage renal disease (ESRD), and its mortality rate is 10 to 20 times that of the general population. CVD exists in the early stage of CKD, and its incidence and severity increase with the progress of renal function, reaching the peak of ESRD. Hypertension is one of the most important factors affecting the occurrence and development of CVD in CKD patients. Therefore, reasonable blood pressure reduction is extremely important. The author explains how to reduce blood pressure reasonably from the following four aspects to reduce CVD.

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blood pressure target

If there are no heart-sticking vascular complications, the blood pressure target is Less than or equal to 130/80 mmHg in patients with proteinuria <1.0g 4h,="" and="" the="" blood="" pressure="" target="" is="" ≤125/75mmhg="" in="" patients="" with="" proteinuria="" ≥1.0g/24h,="" and="" the="" elderly="" patients="" should="" be="" appropriately="">

The effect of blood pressure on CVD incidence and mortality has two characteristics, one is strong, and the other is long-lasting, so every 1mmHg increase in blood pressure is important. Office systolic blood pressure (SBP) or diastolic blood pressure (DBP) were continuously, independently, and directly correlated with the risk of stroke and coronary heart disease (CAD) events, ranging from 115/75mmHg to 185/115mmHg, with every 20mmHg or DBP increase in SBP For every 10mmHg increase, the risk of cardiovascular and cerebrovascular complications doubles. In 2007, the American Heart Association recommended target blood pressure <130 0mmhg="" for="" patients="" with="" a="" high="" risk="" of="" cad="" including="" ckd,="" and="" for="" those="" with="" left="" ventricular="" dysfunction,="" target="" blood="" pressure=""><120>

Hypertension and proteinuria are not only the main clinical manifestations of CKD, but also the main risk factors for the development of CKD and CVD, and the two have a synergistic effect. Evidence-based medicine has confirmed that compared with conventional blood pressure control (130/80mmHg), stricter blood pressure control (125/75mmHg) for patients with urinary protein Greater than or equal to 1.0g/24h can more effectively delay the progression of CKD and the occurrence of CVD  develop.

antihypertensive drugs

Angiotensin-converting enzyme inhibitors (ACEI) and/or angiotensin receptor blockers (ARB) are the first choice for antihypertensive treatment in CKD patients, and calcium channel blocker (CCB) is the first choice for kidney transplant recipients in the first half year after surgery. , especially in patients with proteinuria, ACEI, and (or) ARB are preferred.

Elderly patients with CKD can choose ACEI or ARB but must be cautious. The degree of renal damage and the activation of the renin-angiotensin-aldosterone system (RAS) also play an important role in the development of CVD. The incidence and severity of CVD increased with decreasing GFR. Therefore, the selection of antihypertensive drugs for CKD patients should not only consider the efficacy and characteristics of the drugs, which are strong, durable, and stable, but also whether they can reduce proteinuria, delay the progression of renal insufficiency, and inhibit RAS activation. ACEI combined with ARB has a synergistic effect in reducing proteinuria, and it is advocated for combined application in CKD patients. Recent clinical studies have shown that patients receiving direct renin inhibitor (DRI) combined with losartan treatment have a further 20 percent lower urinary albumin/creatinine ratio than those receiving losartan alone, and there is no significant difference in adverse reactions between the two groups of patients. . Clinical studies of aldosterone antagonists consistently demonstrated a decrease in urinary albumin excretion (UAE) in combination with ACEI or ARB, as well as a mild decrease in glomerular filtration rate (GFR) and SBP, but at the risk of hyperkalemia. Recent studies have shown that the endothelin receptor A antagonist sitaxsentan can further reduce proteinuria, lower blood pressure, improve arterial stiffness and reduce central augmentation index (cAIx) based on ACEI and ARB blockade of RAS.

In addition to lowering blood pressure, RAS inhibitors can also reduce proteinuria and delay the progression of renal insufficiency. The efficacy of these two aspects is related to the dose of the drug, and the optimal dose for reducing proteinuria is higher than the conventional dose. Studies have shown that the optimal dose of benazepril for Chinese CKD patients to reduce urinary protein is 6 percent , 61 percent , 16 percent , 4 percent , and 4 percent for those with 10, 20, 30, 40, and 40 mg/d or more, respectively. The optimal dose of losartan to reduce urinary protein in Chinese CKD patients was 7 percent , 57 percent , 14 percent , 11 percent , and 4 percent for those with 50, 100, 150, 200, and 200 mg/d or more, respectively. Therefore, to reduce proteinuria and delay the progression of renal insufficiency, ACEI combined with ARB can be considered. ACEI should be used first. If there is no GFR decline or hyperkalemia, ACEI/ARB dose titration can also be considered after adding ARB for 1 to 2 weeks. ; If the patient can tolerate it, 2 times the single tablet dose can also be considered. When using ACEI (or) ARB, renal function and serum potassium should be monitored, and the dose should be adjusted according to the changes in these two aspects. For non-dialysis patients with serum creatinine Greater than or equal to 265.2 μmol/L, new ACEI Greater than or equal to 353.6 μmol/L is not recommended, and new ARB is not recommended. After starting regular dialysis, antihypertensive drugs should be switched to ACEI/ARB to improve local tissue remodeling and delay the occurrence and development of CVD. Diabetic nephropathy (DN), especially advanced DN, can be complicated by type IV renal tubular acidosis, and hyperkalemia should be especially vigilant when using ACEI/ARB. In patients with dehydration complications such as diarrhea, vomiting, or high fever, it is wise to reduce or even discontinue ACEIs or ARBs. Long-acting CCBs, beta-blockers, vasodilators, and/or diuretics can be selected or added to patients with contraindications, intolerance, or poor efficacy of ACEI/ARB. Of interest is the efficacy of DRIs, aldosterone antagonists, and endothelin receptor A antagonists in hypertensive patients with CKD.

non-drug antihypertensive

Advocating a healthy lifestyle, especially emphasizing the reduction of sodium intake and weight control, is the basis of blood pressure.

Poor lifestyle and weight gain are not only risk factors for hypertension, but also risk factors for CVD, and are also important factors affecting the efficacy of drugs. The author recommends that regardless of whether Chinese CKD patients have hypertension, they should maintain a body mass index (BMI) of 18-23 kg/m²; limit sodium intake, sodium chloride <6 g/d;="" engage="" in="" cardiovascular="" function="" that="" is="" compatible="" and="" tolerated="" the="" minimum="" standard="" is="" to="" exercise="" five="" times="" a="" week,="" limit="" drinking="" for="" 30="" minutes="" each="" time,="" and="" control="" the="" daily="" drinking="" amount="" to="" be="" less="" than="" 30g="" (men)="" and="" 20g="" (women)="" [alcohol="" intake="" (g)="drinking" amount="" (ml)="" ×="" alcohol="" content="" (="" %)="" ×="" 0.8];="" no="" smoking;="" reduce="" mental="" stress="" and="" maintain="" psychological="">

Treatments other than depressurization

The management of other traditional risk factors for CVD, uremia-related risk factors, and dialysis-related risk factors are also important measures to reduce CVD in patients with CKD. (1) Lowering lipids: maintain low-density lipoprotein cholesterol <1.8 mmol/l="" (70="" mg/dl),="" triacylglycerol=""><1.7 mmol/l="" (150="" mg/dl),="" and="" high-density="" lipoprotein="" cholesterol="">1.04 mmol/L (40 mg/dl) mg/dl, men) or 1.3mmol/L (50mg/dl, women). (2) Strictly control blood sugar, maintain fasting blood sugar <6.1mmol ,="" postprandial="" blood="" sugar=""><8.0mmol ,="" and="" glycosylated="" hemoglobin=""><6.5%. (3)="" correct="" anemia="" and="" maintain="" hemoglobin="" 110g/l.="" (4)="" others="" should="" correct="" hyperuricemia,="" reduce="" homocysteinemia,="" and="" fully="" dialysis="" for="" dialysis="">

Choosing an appropriate blood pressure target, maintaining a healthy lifestyle, rationally applying antihypertensive drugs, closely monitoring adverse drug reactions, and combining lipid-lowering, glucose-lowering, uric acid-lowering, and anemia corrections with comprehensive treatments can certainly prevent the occurrence of CVD in CKD patients. rate and severity are minimized.

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