利尿剂用于CKD高血压患者,为何推荐小剂量?

2023-03-17 网络 网络 发表于上海

自20世纪60年代以来,利尿剂一直是降压治疗的基石。利尿剂主要通过排钠,减少细胞外容量,降低外周血管阻力,从而发挥降压作用

自20世纪60年代以来,利尿剂一直是降压治疗的基石。利尿剂主要通过排钠,减少细胞外容量,降低外周血管阻力,从而发挥降压作用1。氢氯噻嗪是临床降压治疗最常用的利尿剂之一。

目前,对于利尿剂在CKD伴高血压患者中的应用,各种指南并未将其作为高血压治疗的首选药物,而是在联合用药中使用,并且推荐小剂量使用1。为何如此推荐?小剂量利尿剂的疗效和安全性究竟如何呢?

小剂量利尿剂疗效确切

《利尿剂治疗高血压的中国专家共识》也指出:低剂量噻嗪类药物可提供接近全效的降压作用2。RCT和Meta分析证实了利尿剂在降低心血管发病率和病死率方面的有效性1

一项涉及195267例高血压患者的Meta分析表明3小剂量利尿剂显著降低卒中、冠心病、心衰等心脑血管事件和心血管死亡及全因死亡风险

这项Meta分析进一步研究发现,小剂量氢氯噻嗪治疗降低心血管事件和死亡率疗效确切3。高血压患者接受6个月以上的小剂量氢氯噻嗪治疗,可显著降低卒中事件风险41%,显著降低卒中和冠心病复合事件风险33%,显著降低卒中、冠心病、心衰复合事件风险26%,显著降低心血管死亡风险21%3

小剂量利尿剂安全性良好

利尿剂的主要不良反应是引起电解质紊乱、影响血脂、血糖和血尿酸代谢,然而这往往发生在大剂量使用时1。由于噻嗪类利尿剂的剂量-反应曲线平坦,小剂量即可达到较好降压效果,而不良反应呈现剂量依赖性,因此推荐使用小剂量氢氯噻嗪2,维持疗效的同时降低不良反应。

对于CKD合并高血压的患者, ARB联用噻嗪类利尿剂联合方案是最新《中国慢性肾脏病患者高血压管理指南》推荐的初始联合治疗方案之一1。ARB与噻嗪类利尿剂合用有协同作用,有利于改善降压效果,抵消不良反应4

小结

综上,小剂量噻嗪类利尿剂降压疗效和降低心血管事件和死亡率疗效确切,且安全性良好。与ARB类药物联用时,不良反应相互抵消,是指南推荐的CKD合并高血压患者降压的优选方案之一。

 

参考文献

1. 中华医学会肾脏病学分会专家组. 中国慢性肾脏病患者高血压管理指南(2023年版)[J]. 中华肾脏病杂志, 2023, 39(1): 48-80.

2. 利尿剂治疗高血压的中国专家共识[J].中华高血压杂志,2011,19(03):214-222.

3. Thomopoulos C, et al. J Hypertens. 2015 Feb;33(2):195-211.

4. 中国高血压防治指南(2018 年修订版). 中国心血管杂志. 2019, 24(1):24-56. 

 

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  1. [GetPortalCommentsPageByObjectIdResponse(id=2121564, encodeId=c22d2121564b2, content=那小剂量到底多少是小剂量是多少?12.5mg,还是25mg,???还是多大?, beContent=null, objectType=article, channel=null, level=null, likeNumber=53, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=ba8c5483320, createdName=廖冬华, createdTime=Fri Mar 24 12:52:30 CST 2023, time=2023-03-24, status=1, ipAttribution=江西省), GetPortalCommentsPageByObjectIdResponse(id=2120287, encodeId=27ef212028ece, content=有收获, beContent=null, objectType=article, channel=null, level=null, likeNumber=52, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=c3c31528806, createdName=gqylhd, createdTime=Sat Mar 18 13:31:38 CST 2023, time=2023-03-18, status=1, ipAttribution=山西省), GetPortalCommentsPageByObjectIdResponse(id=2120271, encodeId=844621202e19e, content=谢谢分享,已认真学习啦, beContent=null, objectType=article, channel=null, level=null, likeNumber=51, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=ec6f8579021, createdName=ms9000000999580875, createdTime=Sat Mar 18 11:32:23 CST 2023, time=2023-03-18, status=1, ipAttribution=云南省), GetPortalCommentsPageByObjectIdResponse(id=2120270, encodeId=20e521202e0db, content=谢谢分享,已认真学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=71, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=ec6f8579021, createdName=ms9000000999580875, createdTime=Sat Mar 18 11:31:43 CST 2023, time=2023-03-18, status=1, ipAttribution=云南省), GetPortalCommentsPageByObjectIdResponse(id=2120248, encodeId=e8c32120248e3, content=感谢分享,有收获, beContent=null, objectType=article, channel=null, level=null, likeNumber=59, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=2d114843943, createdName=1013100771, createdTime=Sat Mar 18 07:56:17 CST 2023, time=2023-03-18, status=1, ipAttribution=山东省), GetPortalCommentsPageByObjectIdResponse(id=2120220, encodeId=6e28212022039, content=认真学习了。, beContent=null, objectType=article, channel=null, level=null, likeNumber=54, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/NUyjXTCJjo6EF3hKja8nER8RMzxQdria9eCYFhgLTLsDOeqnvIYdeLDz5eP6EnicLuE5gibiawgno4zUA0jAR7Nbtp2llQ9fs3Mk/0, createdBy=278f1986883, createdName=医鸣惊人, createdTime=Fri Mar 17 22:05:42 CST 2023, time=2023-03-17, status=1, ipAttribution=山西省)]
    2023-03-24 廖冬华 来自江西省

    那小剂量到底多少是小剂量是多少?12.5mg,还是25mg,???还是多大?

    0

  2. [GetPortalCommentsPageByObjectIdResponse(id=2121564, encodeId=c22d2121564b2, content=那小剂量到底多少是小剂量是多少?12.5mg,还是25mg,???还是多大?, beContent=null, objectType=article, channel=null, level=null, likeNumber=53, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=ba8c5483320, createdName=廖冬华, createdTime=Fri Mar 24 12:52:30 CST 2023, time=2023-03-24, status=1, ipAttribution=江西省), GetPortalCommentsPageByObjectIdResponse(id=2120287, encodeId=27ef212028ece, content=有收获, beContent=null, objectType=article, channel=null, level=null, likeNumber=52, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=c3c31528806, createdName=gqylhd, createdTime=Sat Mar 18 13:31:38 CST 2023, time=2023-03-18, status=1, ipAttribution=山西省), GetPortalCommentsPageByObjectIdResponse(id=2120271, encodeId=844621202e19e, content=谢谢分享,已认真学习啦, beContent=null, objectType=article, channel=null, level=null, likeNumber=51, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=ec6f8579021, createdName=ms9000000999580875, createdTime=Sat Mar 18 11:32:23 CST 2023, time=2023-03-18, status=1, ipAttribution=云南省), GetPortalCommentsPageByObjectIdResponse(id=2120270, encodeId=20e521202e0db, content=谢谢分享,已认真学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=71, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=ec6f8579021, createdName=ms9000000999580875, createdTime=Sat Mar 18 11:31:43 CST 2023, time=2023-03-18, status=1, ipAttribution=云南省), GetPortalCommentsPageByObjectIdResponse(id=2120248, encodeId=e8c32120248e3, content=感谢分享,有收获, beContent=null, objectType=article, channel=null, level=null, likeNumber=59, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=2d114843943, createdName=1013100771, createdTime=Sat Mar 18 07:56:17 CST 2023, time=2023-03-18, status=1, ipAttribution=山东省), GetPortalCommentsPageByObjectIdResponse(id=2120220, encodeId=6e28212022039, content=认真学习了。, beContent=null, objectType=article, channel=null, level=null, likeNumber=54, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/NUyjXTCJjo6EF3hKja8nER8RMzxQdria9eCYFhgLTLsDOeqnvIYdeLDz5eP6EnicLuE5gibiawgno4zUA0jAR7Nbtp2llQ9fs3Mk/0, createdBy=278f1986883, createdName=医鸣惊人, createdTime=Fri Mar 17 22:05:42 CST 2023, time=2023-03-17, status=1, ipAttribution=山西省)]
    2023-03-18 gqylhd 来自山西省

    有收获

    0

  3. [GetPortalCommentsPageByObjectIdResponse(id=2121564, encodeId=c22d2121564b2, content=那小剂量到底多少是小剂量是多少?12.5mg,还是25mg,???还是多大?, beContent=null, objectType=article, channel=null, level=null, likeNumber=53, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=ba8c5483320, createdName=廖冬华, createdTime=Fri Mar 24 12:52:30 CST 2023, time=2023-03-24, status=1, ipAttribution=江西省), GetPortalCommentsPageByObjectIdResponse(id=2120287, encodeId=27ef212028ece, content=有收获, beContent=null, objectType=article, channel=null, level=null, likeNumber=52, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=c3c31528806, createdName=gqylhd, createdTime=Sat Mar 18 13:31:38 CST 2023, time=2023-03-18, status=1, ipAttribution=山西省), GetPortalCommentsPageByObjectIdResponse(id=2120271, encodeId=844621202e19e, content=谢谢分享,已认真学习啦, beContent=null, objectType=article, channel=null, level=null, likeNumber=51, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=ec6f8579021, createdName=ms9000000999580875, createdTime=Sat Mar 18 11:32:23 CST 2023, time=2023-03-18, status=1, ipAttribution=云南省), GetPortalCommentsPageByObjectIdResponse(id=2120270, encodeId=20e521202e0db, content=谢谢分享,已认真学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=71, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=ec6f8579021, createdName=ms9000000999580875, createdTime=Sat Mar 18 11:31:43 CST 2023, time=2023-03-18, status=1, ipAttribution=云南省), GetPortalCommentsPageByObjectIdResponse(id=2120248, encodeId=e8c32120248e3, content=感谢分享,有收获, beContent=null, objectType=article, channel=null, level=null, likeNumber=59, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=2d114843943, createdName=1013100771, createdTime=Sat Mar 18 07:56:17 CST 2023, time=2023-03-18, status=1, ipAttribution=山东省), GetPortalCommentsPageByObjectIdResponse(id=2120220, encodeId=6e28212022039, content=认真学习了。, beContent=null, objectType=article, channel=null, level=null, likeNumber=54, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/NUyjXTCJjo6EF3hKja8nER8RMzxQdria9eCYFhgLTLsDOeqnvIYdeLDz5eP6EnicLuE5gibiawgno4zUA0jAR7Nbtp2llQ9fs3Mk/0, createdBy=278f1986883, createdName=医鸣惊人, createdTime=Fri Mar 17 22:05:42 CST 2023, time=2023-03-17, status=1, ipAttribution=山西省)]
    2023-03-18 ms9000000999580875 来自云南省

    谢谢分享,已认真学习啦

    0

  4. [GetPortalCommentsPageByObjectIdResponse(id=2121564, encodeId=c22d2121564b2, content=那小剂量到底多少是小剂量是多少?12.5mg,还是25mg,???还是多大?, beContent=null, objectType=article, channel=null, level=null, likeNumber=53, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=ba8c5483320, createdName=廖冬华, createdTime=Fri Mar 24 12:52:30 CST 2023, time=2023-03-24, status=1, ipAttribution=江西省), GetPortalCommentsPageByObjectIdResponse(id=2120287, encodeId=27ef212028ece, content=有收获, beContent=null, objectType=article, channel=null, level=null, likeNumber=52, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=c3c31528806, createdName=gqylhd, createdTime=Sat Mar 18 13:31:38 CST 2023, time=2023-03-18, status=1, ipAttribution=山西省), GetPortalCommentsPageByObjectIdResponse(id=2120271, encodeId=844621202e19e, content=谢谢分享,已认真学习啦, beContent=null, objectType=article, channel=null, level=null, likeNumber=51, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=ec6f8579021, createdName=ms9000000999580875, createdTime=Sat Mar 18 11:32:23 CST 2023, time=2023-03-18, status=1, ipAttribution=云南省), GetPortalCommentsPageByObjectIdResponse(id=2120270, encodeId=20e521202e0db, content=谢谢分享,已认真学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=71, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=ec6f8579021, createdName=ms9000000999580875, createdTime=Sat Mar 18 11:31:43 CST 2023, time=2023-03-18, status=1, ipAttribution=云南省), GetPortalCommentsPageByObjectIdResponse(id=2120248, encodeId=e8c32120248e3, content=感谢分享,有收获, beContent=null, objectType=article, channel=null, level=null, likeNumber=59, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=2d114843943, createdName=1013100771, createdTime=Sat Mar 18 07:56:17 CST 2023, time=2023-03-18, status=1, ipAttribution=山东省), GetPortalCommentsPageByObjectIdResponse(id=2120220, encodeId=6e28212022039, content=认真学习了。, beContent=null, objectType=article, channel=null, level=null, likeNumber=54, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/NUyjXTCJjo6EF3hKja8nER8RMzxQdria9eCYFhgLTLsDOeqnvIYdeLDz5eP6EnicLuE5gibiawgno4zUA0jAR7Nbtp2llQ9fs3Mk/0, createdBy=278f1986883, createdName=医鸣惊人, createdTime=Fri Mar 17 22:05:42 CST 2023, time=2023-03-17, status=1, ipAttribution=山西省)]
    2023-03-18 ms9000000999580875 来自云南省

    谢谢分享,已认真学习

    0

  5. [GetPortalCommentsPageByObjectIdResponse(id=2121564, encodeId=c22d2121564b2, content=那小剂量到底多少是小剂量是多少?12.5mg,还是25mg,???还是多大?, beContent=null, objectType=article, channel=null, level=null, likeNumber=53, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=ba8c5483320, createdName=廖冬华, createdTime=Fri Mar 24 12:52:30 CST 2023, time=2023-03-24, status=1, ipAttribution=江西省), GetPortalCommentsPageByObjectIdResponse(id=2120287, encodeId=27ef212028ece, content=有收获, beContent=null, objectType=article, channel=null, level=null, likeNumber=52, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=c3c31528806, createdName=gqylhd, createdTime=Sat Mar 18 13:31:38 CST 2023, time=2023-03-18, status=1, ipAttribution=山西省), GetPortalCommentsPageByObjectIdResponse(id=2120271, encodeId=844621202e19e, content=谢谢分享,已认真学习啦, beContent=null, objectType=article, channel=null, level=null, likeNumber=51, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=ec6f8579021, createdName=ms9000000999580875, createdTime=Sat Mar 18 11:32:23 CST 2023, time=2023-03-18, status=1, ipAttribution=云南省), GetPortalCommentsPageByObjectIdResponse(id=2120270, encodeId=20e521202e0db, content=谢谢分享,已认真学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=71, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=ec6f8579021, createdName=ms9000000999580875, createdTime=Sat Mar 18 11:31:43 CST 2023, time=2023-03-18, status=1, ipAttribution=云南省), GetPortalCommentsPageByObjectIdResponse(id=2120248, encodeId=e8c32120248e3, content=感谢分享,有收获, beContent=null, objectType=article, channel=null, level=null, likeNumber=59, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=2d114843943, createdName=1013100771, createdTime=Sat Mar 18 07:56:17 CST 2023, time=2023-03-18, status=1, ipAttribution=山东省), GetPortalCommentsPageByObjectIdResponse(id=2120220, encodeId=6e28212022039, content=认真学习了。, beContent=null, objectType=article, channel=null, level=null, likeNumber=54, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/NUyjXTCJjo6EF3hKja8nER8RMzxQdria9eCYFhgLTLsDOeqnvIYdeLDz5eP6EnicLuE5gibiawgno4zUA0jAR7Nbtp2llQ9fs3Mk/0, createdBy=278f1986883, createdName=医鸣惊人, createdTime=Fri Mar 17 22:05:42 CST 2023, time=2023-03-17, status=1, ipAttribution=山西省)]
    2023-03-18 1013100771 来自山东省

    感谢分享,有收获

    0

  6. [GetPortalCommentsPageByObjectIdResponse(id=2121564, encodeId=c22d2121564b2, content=那小剂量到底多少是小剂量是多少?12.5mg,还是25mg,???还是多大?, beContent=null, objectType=article, channel=null, level=null, likeNumber=53, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=ba8c5483320, createdName=廖冬华, createdTime=Fri Mar 24 12:52:30 CST 2023, time=2023-03-24, status=1, ipAttribution=江西省), GetPortalCommentsPageByObjectIdResponse(id=2120287, encodeId=27ef212028ece, content=有收获, beContent=null, objectType=article, channel=null, level=null, likeNumber=52, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=c3c31528806, createdName=gqylhd, createdTime=Sat Mar 18 13:31:38 CST 2023, time=2023-03-18, status=1, ipAttribution=山西省), GetPortalCommentsPageByObjectIdResponse(id=2120271, encodeId=844621202e19e, content=谢谢分享,已认真学习啦, beContent=null, objectType=article, channel=null, level=null, likeNumber=51, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=ec6f8579021, createdName=ms9000000999580875, createdTime=Sat Mar 18 11:32:23 CST 2023, time=2023-03-18, status=1, ipAttribution=云南省), GetPortalCommentsPageByObjectIdResponse(id=2120270, encodeId=20e521202e0db, content=谢谢分享,已认真学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=71, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=ec6f8579021, createdName=ms9000000999580875, createdTime=Sat Mar 18 11:31:43 CST 2023, time=2023-03-18, status=1, ipAttribution=云南省), GetPortalCommentsPageByObjectIdResponse(id=2120248, encodeId=e8c32120248e3, content=感谢分享,有收获, beContent=null, objectType=article, channel=null, level=null, likeNumber=59, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=2d114843943, createdName=1013100771, createdTime=Sat Mar 18 07:56:17 CST 2023, time=2023-03-18, status=1, ipAttribution=山东省), GetPortalCommentsPageByObjectIdResponse(id=2120220, encodeId=6e28212022039, content=认真学习了。, beContent=null, objectType=article, channel=null, level=null, likeNumber=54, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/NUyjXTCJjo6EF3hKja8nER8RMzxQdria9eCYFhgLTLsDOeqnvIYdeLDz5eP6EnicLuE5gibiawgno4zUA0jAR7Nbtp2llQ9fs3Mk/0, createdBy=278f1986883, createdName=医鸣惊人, createdTime=Fri Mar 17 22:05:42 CST 2023, time=2023-03-17, status=1, ipAttribution=山西省)]
    2023-03-17 医鸣惊人 来自山西省

    认真学习了。

    0

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