【高血压英文课件】Hypertension-in-CKD

HypertensioninCKDMichaelJCasey,MDWakeNephrologyAssociatesHypertensioninCKDMichaelJC1HypertensionStatsHTNaffectsapproximately1billionworldwide$500billionindirectcostsContinuous,consistentandindependentrelationshipbetweenBPandCadsForthoseage40-70,eachincreasedincrementof20/10mmHginBPdoublestheriskofCVDacrosstheentireBPrangeof115/75to185/115.Only35%ofhypertensivepatientsontreatmentareundercontrol.HypertensionStatsHTNaffects2HypertensionasDefinedbyJNCVII120/80-normal;“optimal”121-139/80-89-“pre-hypertension”ControversialMoreahealthpolicystatement140-160/90-100-Stage1Hypertension>160/100-Stage2HypertensionHypertensionasDefinedbyJNC3【高血压英文课件】Hypertension-in-CKD4【高血压英文课件】Hypertension-in-CKD5MeasurementofBloodPressureSeatedpositionwitharmsupportedidealAllowpatienttosettleforseveralminutesPropersizedcuffBladdertoencircle80–100%armBladderwidth40-50%ofarmConfirm2readings5minutesapartinbotharmsforinitialdiagnosisIftakeninwristorlegs,thecuffmustbeattheleveloftheheartMeasurementofBloodPressureS6BPMeasurementBPMeasurement7HomeBPMonitoringSelfreadingsorcontinuousambulatorymonitoringHelpfuladjuncttoofficereadingsMorereadingsinpatientsusualenvironmentBettercorrelatedwithcardiovascularoutcomesImprovespatientcomplianceHelpsclarifysymptomsDefinesmaskedandwhitecoathypertensionHomeBPMonitoringSelfreading8HomeBPMonitoringPatientsneedtobetaughtpropermethodsNowristcuffsSemi-automatedelectroniccuffsCuffneedstobecheckedagainstofficereadingsFrequencyofmonitoringcanvaryAllcurrentoutcomedata/guidelines/trailsarefromofficereadingsHomeBPMonitoringPatientsnee9AmbulatoryBPMonitoringAmbulatoryBPMonitoring10AmbulatoryBPMonitoringAmbulatoryBPMonitoring11AmbulatoryBPMonitoringMorereproduciblethanofficemeasurementsHelpfulinearlydiagnosisUnexplainedmicroalbuminuriaorLVHWhiteCoatHypertensionResistantHypertensionNolongtermstudiesyetAmbulatoryBPMonitoringMorer12PrevalenceofHTNinCKDPrevalenceofHTNinCKD13HypertensioninCKD80%ofpatientswithCKDhaveHBPMoststartwithessentialhypertensionAsGFRdecreasesitismoredependentonsalt/waterretentionfromdecreasedGFRCKDpatientsalsohavederangementsintheRenin/Angiotensin/AldosteronesystemHypertensioninCKD80%ofpati14TreatmentofHypertensionGoaldependsondiseasestate<130/80ifDM,CKD,CVDz<125/75ifCKDwithproteinuriaSBPistheissueintheoldDiastolicHBPisaproblemoftheyoungReachingthetargetismoreimportantthanhowyougetthereMultipleinterventionsarenecessaryinmostTreatmentofHypertensionGoal15HypertensiveEmergenciesHypertensionisachronicoutpatientdiseasewithrareacutesideeffectsHeadache,MSchanges,ICH,Papilledema,CHF,Angina,Renalfailurewithhematuria,HemorrhageareemergenciesrequirehospitalizationOtherwisetreatasymptomaticsevereHBPoverdays/weeksClonidineeffectiveforoutpatientacuteBPloweringHoldESAHypertensiveEmergenciesHypert16ProgressionofCKDandBPProgressionofCKDandBP17【高血压英文课件】Hypertension-in-CKD18BP=COXSVRBP=HRXStrokeVolumeXSVRCO=cardiacoutputSVR=systemicvascularresistanceBPFormulaBP=COXSVRBPFormula19LifestyleModificationFirst(Always)LowSalt(3gm/day)DASHdietExerciseTobaccoAlcoholSleepApneaNSAIDSDecongestantsDietPillsLifestyleModificationFirst20RenininhibitorsRenininhibitors21【高血压英文课件】Hypertension-in-CKD22RAASAgentsACEInhibitorscaptopril,enalapril,lisinopril,ramipril…AngiotensinReceptorBlockerslosartan,irbesartan,valsartan,telmisartan…DirectReninInhibitors-aliskirenAldosteroneReceptorBlockersspironolactone,eplerenoneDrugsofChoiceinCKDNotinpregnancyRAASAgentsACEInhibitors23ACEI/ARBinCKDTrialPOPULATIONDRUGViberti;JAMA94Type1DMCaptoprilREIN,KI98NephroticRamiprilAASK;JAMA02AAptswCKDRamiprilIRMA2;NEJM01Type2DMValsartanIDNT;NEJM01Type2DMIrbesartanRENAAL;NEJM01Type2DMLosartanMicro-HopeHighriskCVDzRamiprilACEI/ARBinCKDTrialPOPULATION24GlomerularPerfusionGlomerularPerfusion25ACEInhibitorsFirstclassdrugforallCKDpatientsShouldbeconsideredinallstagesIftoleratedthenreduceddevelopmentofESRD,CKDprogressionBestoutcomedatainproteinuricCKDAngioedemaandcoughHyperkalemiaandworseningrenalfunctionACEInhibitorsFirstclassdrug26AngiotensinReceptorBlockersNextchoiceafterACEIbecauseofcostEqualoutcomedataatthispointNoCoughSameissueswithhyperkalemiaandARFCombowithACEIcomingunderfireAngiotensinReceptorBlockersN27DirectReninInhibitorsAliskiren(Tekturna)isonlydrugFirstnewantihypertensiveclassin15yearsPromisingrenal/CHFdatabutnohardoutcomesMaybeusefulforproteinuriareductionincombowithARBGIupsetSameissueofhyperkalemiaandARFaswithallRAASagentsDirectReninInhibitorsAliskir28AldosteroneBlockersPotassiumsparingdiureticsCanboostefficacyofloopdiureticsImprovessurvivalinCHFpatientsReductioninproteinuria+/-otherRAASagentsGynecomastiawithspironolactoneSameissueofhyperkalemiaandARFAldosteroneBlockersPotassium29DiureticsKeytoHBPmanagementinnon-ESRDCKDRAASagentsynergyThiazides:hydrochlorothiazide;chlorthalidone,metolazoneK-Sparing:amiloride,triamterene,spironolactone,eplerenoneLoops:furosemide,bumetanide,torsemideDiureticsKeytoHBPmanagement30ThiazideDiureticsJNCfirstchoiceBPmedVeryeffectiveinmultipletrialsOftenavailableincombowithRAASagentLowK,increaseBG,lipidsatdose>25mgIneffectiveatGFR<50CanboostefficacyofloopdiureticsThiazideDiureticsJNCfirstc31LoopDiureticsNecessarytomaintainvolumestatusinGFR<50FurosemideisclassicbutshorthalflifesopoorforHBPBumetanideissamebutbetterabsorbedTorsemidehasmuchlongerhalf-lifeandismychoicenowthatitisgenericTitratetoincreaseUOPthenincreasefrequencyLowpotassiumismainissue,especiallywiththiazides(metolazone)LoopDiureticsNecessarytomai32BetaBlockersSelectiveBetaBlockersAtenolol,metoprolol,bisoprolol,nebivololNon–selectiveBetaBlockersPropranololAlpha–BetaBlockersLabetolol,carvedololBetaBlockersSelectiveBetaBl33BetaBlockersNextclassinCKDpatientsReducesHR,SVandalsoreninReducesincidenceofsuddencardiacdeathandarrhythmiasReducesCVeventsinCHF,post-MICounter-actsreflexincreaseinHR/COinducedbyvasodilatorsanddiureticsBetaBlockersNextclassinCKD34BetaBlockersCarvedolol,labetololarebetterforHBPAtenolol,metoprololbetterforCHF,HRreductionandarrhythmiaPropranololforascites/cirrhosis,anxietyBradycardiaandfatiguearemainsideeffectsBetaBlockersCarvedolol,labet35CentralAdrenergicAgentsClonidineispredominantdrugProbablysamebenefitsasbblockersNostudiesandneverwillbeSynergywithbblockersdebatableDrymouth,fatigue,t.i.d.,bradycardiaGoodforacuteHBP/prnusePatchavailableMethyldopaforHBPinpregnancyCentralAdrenergicAgentsCloni36DihydropyridineCalciumChannelBlockersNifedipine,amlodipine,felodipineDirectvasodilatorsVeryeffective–prob4thdrugofchoiceCancauseperipheraledemaespeciallyinfemalesNoeffectonHR,CHFIncreaseGFR,proteinuriaDihydropyridineCalciumChanne37GlomerularPerfusionGlomerularPerfusion38Non-DihydropyridineCCB’sDiltiazemandVerapamilReduceHRandLowerBPArrhythmiacontrolReductioninproteinuriabutnorenaloutcomesEdema,bradycardia,gingivalhyperplasia,CyP450interactionsNon-DihydropyridineCCB’sDilti39OtherVasodilatorsAlphablockers–doxazosin,terazosin,prazosinHelpwithBHPOncedailyOrthostatichypertension,tachycardia,CHFHydralazineImprovedoutcomesinAAwithCHFBIDorTIDLupussyndromeModeratelyeffectiveOtherVasodilatorsAlphablocke40MinoxidilMostpotentantihypertensiveagentSeverereboundtachycardiaandedemaNeedbetablockerandloopdiureticHairgrowthPericarditisInexpensiveMinoxidilMostpotentantihy41HypertensioninESRDGreatareaofdebateRAASAgentsandBetablockersmayimproveoutcomesinnon-RCTsWhatiscorrectmeasurement?Pre-HDBPPost-HDBPHomeBPWhentotake/holdBPMedsHypertensioninESRDGreatarea42HypertensioninESRDHypertensioninESRD43HypertensioninESRDHypertensioninESRD44HypertensioninESRDHypertensioninESRD45HypertensioninESRDJ-shapedcurveofsurvivalvsBPinESRDBettersurvivalwithmoderateHBPOnlycomparedtootherESRD?Skewedbyyoungpatients?SkewedbycardiomyopathyMostHBPisduetoinadequatevolumecontrolDecreaseinterdialyticweightgainChallengeweightLongerHDtimes(daily,nocturnal,PD)HypertensioninESRDJ-shapedc46【高血压英文课件】Hypertension-in-CKD47TreatmentofHBPinESRDGraduallychallengeweighteachHDNoedemaCrampingLowBPManagementofintradialyticHBPUFprofilingNa+modelingLowerdialysatetemperatureCarnitenelevelsTreatmentofHBPinESRDGradua48TreatmentofHBPinESRDDonotholdBetablockers/Clonidinebeforedialysis(MYOPINION)Short