肾移植高血压患者药学监护讲课课件

肾移植高血压患者药学监护肾移植高血压患者药学监护1（优选）肾移植高血压患者药学监护（优选）肾移植高血压患者药学监护2TutoneVK,etal.Pharmaceutical30mgQ12hRTRs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%CurrentmedicationPharmaceuticalSaltrestrictionOptimalbloodlevelsofBloodpressure>=140/90Assessinformation(patientassess)ClinTransplant2005:19:181–192.MedicalCare40mgqdTreatmenthypertension

Drug130/85mmHgforrenaltransplantrecipientswithoutproteinuriaCaseStudyPatientdetails(renaltransplantation)

Number:4438420Sex:MaleWeight:63kgHigh:160cmDateofBirth:1943/02/09Age:63yearsDisease:ChronicnephritisOperationdate:

2006/04/19CadavericColdischemiatime(hours):12

Heatischemiatime(minutes):5TutoneVK,etal.CaseStudyPat3CurrentmedicationImmunosuppressiveregimentsCyclosporine100mgBid125mgBidALG250mgQDMizoribine100mgQD,50mgQNMycophenolatemofetil750mgBidMethylprednisolone500mgQd3d

Prednisolone30mgQdCurrentmedicationImmunosuppre4CurrentantihypertensivemedicationsMetoprolol12.5mgQ12hNifedipineControlledreleased30mgqd30mgQ12hEnalapril10mgQ12hFurosemide40mgtid

40mgqd

Currentantihypertensivemedic5172/89172/896患者医师药剂师护士MedicalCareNursingCareDrugInformation＆Pharmaceutical

CareInformationDrugInformation＆Pharmaceutical

CareInformation以患者为中心、以人为本PharmaceuticalCare患者医师药剂师护士MedicalCareNursing7PharmaceuticalcareandpatientassessmentInitiaterelationshipwithpatient

Gatherpatientinformation(subjectiveandobjective)Assessinformation(patientassess)CompletetheinterventionDeveloppharmaceuticalcareplan

Implementfollow-upPharmaceuticalcareandpatien8GraftandpatientsurvivalKaplan–MeieranalyseswiththepopulationdividedintoquintilesofsystolicBPTutoneVK,etal.ClinTransplant2005:19:181–192.GraftandpatientsurvivalKap9GraftandpatientsurvivalKaplan–Meieranalyseswiththepopulation

dividedintoquintilesofdiastolicBP

TutoneVK,etal.ClinTransplant2005:19:181–192.GraftandpatientsurvivalKap10Summaryofantihypertensiveswithpatientandgraftoutcomes

BB,beta-blocker;CC,calciumchannelblocker;Loop,loopdiuretic;ACEI,angiotensinconvertingenzymeinhibitor;ARB,angiotensinreceptorantagonistSummaryofantihypertensivesw11DiagnosisandtreatmentofhypertensionintherenaltransplantrecipientContinueanti-hypertensivetherapyReassessperiodicallyAdministeranti-hypertensiveAgent(CA,ACEI,orotherBloodpressure>=140/90StableGFR?InterventionfailstonormalizeBPConsidersaltrestrictionand/ordiureticMultidrugregimen;addagentsofdifferentclassesasnecessaryReducedoseofcyclosporineortacrolimusEvaluateallograftfunctionOptimalbloodlevelsofcyclosporineortacrolimusECGvolumestatusacceptable?Adequateresponsetotherapy?AcceptableADR?Adequateresponsetotherapy?Re-evaluateallograftfunctionanddrugtherapyConsiderTRASNoYesYesYesNoNoNoNoYesYesYesDiagnosisandtreatmentofhyp12Frequencyofhypertension6085%renaltransplantrecipients90%renaltransplantrecipientsadministratedCsAFrequencyofhypertension608513acceptable?Ifthesevariablesarestable,itisreasonabletoproceedwithantihypertensivetherapyAdequateresponsetotherapy?ACEIandARBarealsoeffective;theiruserequiresclosemonitoringofrenalfunction,serumpotassiumlevels,andhematocritlevels(subjectiveandobjective)TutoneVK,etal.ACEI,angiotensinconvertingenzymeinhibitor;ARB,angiotensinreceptorantagonistMedicalCareTutoneVK,etal.Bloodpressurereadingsconsistentlyover140/90mmHgDrugInformation＆Verapamil,diltiazem,nicardipine,andmibefradilincreasebloodlevelsofcyclosporineandtacrolimusandshouldbeusedwithcaution.Causeofhypertension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acceptable?Causeofhypertensi14Bloodpressurereadingsconsistentlyover140/90mmHg(subjectiveandobjective)GraftandpatientsurvivalKaplan–MeieranalyseswiththepopulationCalciumantagonists(CA)areeffectiveagentsandmayoffertheaddedbenefitofattenuatingcyclosporineinducedchangesinrenalhemodynamics.Assessmentofallograftfunction,extracellularfluidvolume(ECF)status,andimmunosuppressivedosingBB,beta-blocker;CC,calciumchannelblocker;Loop,loopdiuretic;ClinTransplant2005:19:181–192.StableGFR?DrugInformation＆(subjectiveandobjective)ACEI,angiotensinconvertingenzymeinhibitor;ARB,angiotensinreceptorantagonistanddrugtherapy130/85mmHgforrenaltransplantrecipientswithoutproteinuriaInitiaterelationshipwithpatientCurrentantihypertensivemedicationsRiskFactor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Bloodpressurereadingsconsist15DiagnosishypertensionBloodpressurereadingsconsistentlyover140/90mmHgAssessmentofallograftfunction,extracellularfluidvolume(ECF)status,andimmunosuppressivedosingIfthesevariablesarestable,itisreasonabletoproceedwithantihypertensivetherapyDiagnosishypertensionBloodpr16Treatmenthypertension130/85mmHgforrenaltransplantrecipientswithoutproteinuria125/75mmHgforproteinuricpatients

Treatmenthypertension130/8517Bloodpressurereadingsconsistentlyover140/90mmHgacceptable?InitiaterelationshipwithpatientAntihypertensivemedicationsintherenaltransplantrecipientStableGFR?CalciumchannelblockIfthesevariablesarestable,itisreasonabletoproceedwithantihypertensivetherapyGraftandpatientsurvivalKaplan–Meieranalyseswiththepopulation

dividedintoquintilesofdiastolicBPCurrentmedicationCurrentantihypertensivemedicationsACEinhibitor6085%renaltransplantrecipientsTreatmenthypertension

DrugModificationoftheimmunosuppressivetherapyCalciumchannelblockACEinhibitorARBBloodpressurereadingsconsist18(subjectiveandobjective)Bloodpressurereadingsconsistentlyover140/90mmHgPharmaceuticalcareandpatientassessmentTutoneVK,etal.Adequateresponsetotherapy?Treatmenthypertension

nondrugImmunosuppressiveregimentsMedicalCareClinTransplant2005:19:181–192.DiagnosisandtreatmentofhypertensionintherenaltransplantrecipientBloodpressure>=140/90StableGFR?Treatmenthypertension

nondrugAvoidanceofanincreaseinbodyweightSaltrestrictionExerciseSurgery(subjectiveandobjective)Trea19TutoneVK,etal.InitiaterelationshipwithpatientanddrugtherapyTreatmenthypertension

nondrugAdministeranti-hypertensive(subjectiveandobjective)Adequateresponsetotherapy?SaltrestrictionAcceptableADR?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%130/85mmHgforrenaltransplantrecipientswithoutproteinuriaPharmaceuticalAntihypertensivemedicationsintherenaltransplantrecipientCalciumantagonists(CA)areeffectiveagentsandmayoffertheaddedbenefitofattenuatingcyclosporineinducedchangesinrenalhemodynamics.Verapamil,diltiazem,nicardipine,andmibefradilincreasebloodlevelsofcyclosporineandtacrolimusandshouldbeusedwithcaution.ACEIandARBarealsoeffective;theiruserequiresclosemonitoringofrenalfunction,serumpotassiumlevels,andhematocritlevelsDiureticsfrequentlyareusefuladjunctstotherapyinrecipientsowingtothesaltretentionthatoftenaccompaniescyclosporineTutoneVK,etal.Antihypertens20参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参与临床用药工作发现21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药物治疗中的问题与适应证不符22DrugInformation＆Treatmenthypertension

Drug125mgBidContinueanti-hypertensivetherapy6085%renaltransplantrecipientsAssessmentofallograftfunction,extracellularfluidvolume(ECF)status,an