心肾综合征.ppt

心肾综合征,定义,广义上，是指心脏和肾脏中一个器官对另外一个器官的功能损害不能进行代偿，最终导致心脏和肾脏功能的共同损害。 狭义的心肾综合征是特指CHF引起的进行性肾功能损害，并导致肾功能不全，通常认为这是CHF发展到终末期的一种表现。,简化的MDRD研究方程 GFR186 Scr-1.154 年龄-0.203 女性，再乘以0.742 肾功能不全判断标准 GFR 60 mLmin-1（1.73 m2）-1,前言,预后价值,用logistic 回归分析筛选出Scr、GFR和年龄是CHF患者住院期间死亡的危险因素 Scr预测住院期间死亡的价值最大,CHF患者住院期间死亡5个可能的危险因素与赋值,进入方程中的自变量及有关参数的估计值,CHF伴肾功能不全的发病机理,CHF时肾脏血流灌注减少（34） 共同的易患因素 药物影响 恶性循环 （贫血，25.8） CVD 心肾综合征 CHF CKD,利尿剂,在体液潴留纠正前，出现低血压或氮质血症 CHF进展 利尿剂加量 利尿剂过量所引起 利尿剂减量 体液潴留已纠正，出现低血压或氮质血症 利尿剂减量,ACEI,目前ACEI在伴有RI的CHF患者中的益处证据不多。这是因为有关ACEI治疗CHF的临床试验中很少入选对象的Scr超过175 mol/l；没有报道基于肾功能水平的亚组分析结果；排除标准中采用Scr值，而目前推荐用公式估算GFR来反映肾功能。,ACEI,CONSENSUS ( the Cooperative North Scandinavian Enalapril Survival Study )是目前纳入RI患者最多的ACEI治疗CHF的试验。它的一个排除标准为Scr 300 mol/l。Scr均值为132 mol/l。GFR估算值为45 ml/min 。结果依那普利组一年的死亡率下降了31。Scr值在上50位的和下50位的CHF患者同样受益。 Shlipak 等分析了20，902例心肌梗死后发生左心室收缩功能不全的老年患者资料，发现ACEI在Scr 177 mol/l 的患者获益更大（1年死亡率下降了23，而 Scr 177 mol/l 组为18 ）。,ACEI,ACEI在GFR特别依赖于血管紧张素维持的CHF患者应用可引起肾功能恶化。这包括严重的CHF、低钠血症、平均动脉血压持续下降（ 65 mm Hg）、高度双肾动脉狭窄、原有慢性肾脏疾病、合并应用非甾体类抗炎药（NSAID）等患者。,HOME | SUBSCRIBE | CURRENT ISSUE | PAST ISSUES | COLLECTIONS | HELP | Search Term Advanced Search Institution: China | Sign In as Individual | Contact Subscription Administrator at Your Institution | FAQ PreviousVolume 354:131-140 January 12, 2006 Number 2Next Efficacy and Safety of Benazepril for Advanced Chronic Renal Insufficiency Fan Fan Hou, M.D., Ph.D., Xun Zhang, M.D., Guo Hua Zhang, M.D., Ph.D., Di Xie, M.D., Ping Yan Chen, M.D., Wei Ru Zhang, M.D., Ph.D., Jian Ping Jiang, M.D., Min Liang, M.D., Ph.D., Guo Bao Wang, M.D., Zheng Rong Liu, M.D., and Ren Wen Geng, M.D. Full Text PDF PDA Full Text PowerPoint Slide Set Translated Abstracts Editorial by Hebert, L. A. Letters Add to Personal Archive Add to Citation Manager Notify a Friend E-mail When Cited E-mail When Letters Appear Find Similar Articles PubMed Citation ABSTRACT Background Angiotensin-convertingenzyme inhibitors provide renal protection in patients with mild-to-moderate renal insufficiency (serum creatinine level, 3.0 mg per deciliter or less). We assessed the efficacy and safety of benazepril in patients without diabetes who had advanced renal insufficiency. Methods We enrolled 422 patients in a randomized, double-blind study. After an eight-week run-in period, 104 patients with serum creatinine levels of 1.5 to 3.0 mg per deciliter (group 1) received 20 mg of benazepril per day, whereas 224 patients with serum creatinine levels of 3.1 to 5.0 mg per deciliter (group 2) were randomly assigned to receive 20 mg of benazepril per day (112 patients) or placebo (112 patients) and then followed for a mean of 3.4 years. All patients received conventional antihypertensive therapy. The primary outcome was the composite of a doubling of the serum creatinine level, end-stage renal disease, or death. Secondary end points included changes in the level of proteinuria and the rate of progression of renal disease. Results Of 102 patients in group 1, 22 (22 percent) reached the primary end point, as compared with 44 of 108 patients given benazepril in group 2 (41 percent) and 65 of 107 patients given placebo in group 2 (60 percent). As compared with placebo, benazepril was associated with a 43 percent reduction in the risk of the primary end point in group 2 (P=0.005). This benefit did not appear to be attributable to blood-pressure control. Benazepril therapy was associated with a 52 percent reduction in the level of proteinuria and a reduction of 23 percent in the rate of decline in renal function. The overall incidence of major adverse events in the benazepril and placebo subgroups of group 2 was similar. Conclusions Benazepril conferred substantial renal benefits in patients without diabetes who had advanced renal insufficiency. (ClinicalT number, NCT00270426 ClinicalT .) Source Information From the Renal Division, Nanfang Hospital, Southern Medical University, Guangzhou, China. Address reprint requests to Dr. Hou at the Renal Division, Nanfang Hospital, 1838 N. Guangzhou Ave., Guangzhou 510515, China, or at .,ARB,在ELITE等研究中，应用ARB发生肾功能恶化的机会与ACEI相似（10.5%）。为避免肾功能恶化、高钾血症的发生率上升，目前不主张同时应用3种抑制肾素-血管紧张素-醛固酮系统的药物：ACEI、ARB和醛固酮受体阻滞剂。,-受体阻滞剂,在一研究中，伴肾功能不全的心肌梗死（MI）后CHF患者应用-受体阻滞剂获益更大。,醛固酮受体阻滞剂,基于RALES和EPHESUS研究纳入伴肾功能不全的患者非常少。2005年美国成人CHF诊治指南指出，醛固酮受体阻滞剂应有选择地在中、重度CHF患者或MI早期有左室功能不全的患者中应用：他们的Scr 141 mol/L或GFR 30 mLmin-1(1.73m2)-1，血钾 5.0 mmol/L，有条件监测血钾。,地高辛,DIG研究证明地高辛可减少CHF患者的住院率，对生存率没有影响。对肾功能受损、年龄大于70岁或低体重的患者，地高辛应使用低剂量（每天或隔天 0.125 mg）。,阿司匹林,Massie建议对没有冠脉或其它动脉粥样硬化证据的CHF患者，即使有危险因素，不必用阿司匹林预防血管事件。对近来有冠脉事件（不包括陈旧性MI）或心绞痛的患者，可应用小剂量（81 mg）阿司匹林。其中，若患者有进展性或难治性CHF，特别是在正规治疗下仍需频繁住院的患者，可考虑用华法林或氯吡格雷代替阿司匹林。,他汀类药物,基础和临床证据支持他汀类药物具有肾脏保护作用，并有研究提示缺血和非缺血性CHF患者均可从他汀类药物治疗中获益。,展望,2004年美国国立卫生研究院心肺血液研究所成立了研究CHF中心脏和肾脏之间关系的工作组。今后在下述几方面还有待进一步深入研究：心肾综合征的发生机理；现有药物在心肾综合征中应用的策略；新的治疗措施如Nesiritide、超滤的有效性等。,致谢,后面内容直接删除就行 资料可以编辑修改使用 资料可以编辑修改使用 资料仅供参考，实际情况实际分析,