肾移植高血压患者药学监护.ppt

肾移植高血压患者药学监护,胡永芳,Major Contents,Cause of hypertension in the renal transplantation Treatment of hypertension in the renal transplant recipient Anti-hypertension medications,Case Study,Patient details ( renal transplantation) Number : 4438420 Sex: Male Weight: 63 kg High: 160 cm Date of Birth: 1943/02/09 Age: 63 years Disease: Chronic nephritis Operation date: 2006/04/19 Cadaveric Cold ischemia time (hours) : 12 Heat ischemia time (minutes) : 5,Current medication,Immunosuppressive regiments Cyclosporine 100 mg Bid 125 mg Bid ALG 250 mg QD Mizoribine 100 mg QD, 50 mg QN Mycophenolate mofetil 750mg Bid Methylprednisolone 500mg Qd 3d Prednisolone 30mg Qd,Current anti-hypertensive medications,Metoprolol 12.5 mg Q12h Nifedipine Controlled released 30 mg qd 30 mg Q12h Enalapril 10 mg Q12h Furosemide 40mg tid 40mg qd,以患者为中心、以人为本,Pharmaceutical Care,Pharmaceutical care and patient assessment,Graft and patient survival KaplanMeier analyses with the population divided into quintiles of systolic BP,Tutone VK, et al. Clin Transplant 2005: 19: 181192.,Graft and patient survival KaplanMeier analyses with the population divided into quintiles of diastolic BP,Tutone VK, et al. Clin Transplant 2005: 19: 181192.,Summary of anti-hypertensives with patient and graft outcomes,BB, beta-blocker; CC, calcium channel blocker; Loop, loop diuretic; ACEI, angiotensin converting enzyme inhibitor; ARB, angiotensin receptor antagonist,Diagnosis and treatment of hypertension in the renal transplant recipient,Continue anti-hypertensive therapy Reassess periodically,Administer anti-hypertensive Agent (CA, ACEI, or other,Frequency of hypertension,60-85 % renal transplant recipients 90 % renal transplant recipients administrated CsA,Cause of hypertension,免疫抑制剂的使用 移植肾相关的因素 急、慢性排斥反应 慢性移植肾病 肾动脉狭窄,复发性或新发性肾病,药物肾毒性,尿路梗阻 原肾高肾素潴留 红细胞增多症,Risk Factor,免疫抑制剂的升压 移植肾功能受损 移植肾动脉狭窄 RTRs 的平均动脉压每升高10mmHg ,其移植肾脏功能衰竭的发生率上升30 % 肾移植后合并血压升高者急性排斥反应发生率远远高于血压降低者 尸体肾移植较活体肾移植发生率高,Diagnosis hypertension,Blood pressurereadings consistently over 140/90 mmHg Assessment of allograft function, extracellular fluid volume (ECF) status, and immunosuppressive dosing If these variables are stable, it is reasonable to proceed with antihypertensive therapy,Treatment hypertension,130/85 mmHg for renal transplant recipients without proteinuria 125/75 mmHg for proteinuric patients,Treatment hypertension Drug,Modification of the immunosuppressive therapy Calcium channel block ACE inhibitor ARB,Treatment hypertension non drug,Avoidance of an increase in body weight Salt restriction Exercise Surgery,Anti-hypertensive medications in the renal transplant recipient,Calcium antagonists (CA) are effective agents and may offer the added benefit of attenuating cyclosporine induced changes in renal hemodynamics. Verapamil, diltiazem, nicardipine, and mibefradil increase blood levels of cyclosporine and tacrolimus and should be used with caution. ACEI and ARB are also effective; their use requires close monitoring of renal function, serum potassium levels, and hematocrit levels Diuretics frequently are useful adjuncts to therapy in recipients owing to the salt retention that often accompanies cyclosporine,参与临床用药工作,发现 解决 潜在的或实际存在的用药问题 预防,药物治疗中的问题,与适应证不符 需要其他的药物治疗 药物治疗无效 药物剂量过低 药物治疗中出现的不良反应 药物剂量过高 顺从性或依从性较差,安全合理用药教育,医生 肾移植患者抗高血压药的使用 肾移植患者抗生素的使用 护士 多巴胺、氯化钾等注射液输注药物浓度、滴注速度 患者 肾移植患者药物使用 可能出现不良反应 饮食、出院用