中国循环杂志:新版肾动脉狭窄诊断和处理中国专家共识出台:应用中国标准

2017-09-22 佚名 中国循环杂志

随着人口老龄化和血管影像技术的普及,临床实践中发现的肾动脉狭窄患者越来越多。由于肾动脉狭窄的病因多样,临床表现缺乏特异性,治疗策略上仍有较大争议,已有的相关指南和共识对肾动脉狭窄的处理意见也不一致。

随着人口老龄化和血管影像技术的普及,临床实践中发现的肾动脉狭窄患者越来越多。由于肾动脉狭窄的病因多样,临床表现缺乏特异性,治疗策略上仍有较大争议,已有的相关指南和共识对肾动脉狭窄的处理意见也不一致。

因此,中国医疗保健国际交流促进会血管疾病高血压分会近期制定并发布了肾动脉狭窄的诊断和处理中国专家共识

该共识的要点包括:

一、肾动脉狭窄一般定义为肾动脉主干及(或)其分支直径减少≥ 50%,狭窄两端收缩压差≥20 mmHg或平均压差≥10 mmHg。临床上主要表现为肾血管性高血压和缺血性肾病。

二、肾动脉狭窄一般分为动脉粥样硬化性和非动脉粥样硬化性,后者以大动脉炎和纤维肌性发育不良最为常见。

三、肾血管性高血压的药物降压治疗
(1)可选用的药物有ACEI/ARB、钙拮抗剂、β受体阻滞剂等。
(2)ACEI/ARB 可用于单侧肾动脉狭窄,而单功能肾或双侧肾动脉狭窄慎用。
(3)利尿剂激活肾素释放,一般不主张用于肾血管性高血压,但患者如合并原发性高血压、肺水肿或心力衰竭,仍可选用。

四、血管重建治疗

1、狭窄程度

肾动脉狭窄到何种程度必须进行血管重建,目前尚无一致意见,推荐血管重建最小阈值为直径狭窄50%。
对于肾动脉直径狭窄50%~70%的患者,要有明确的血流动力学依据,一般以跨病变收缩压差>20mmHg 或平均压差>10 mmHg 为准。直径狭窄>70%是比较有力的解剖学指征。

2、临床指征
(1)严重高血压(持续高血压Ⅱ~Ⅲ级)、恶性高血压、难治性高血压、高血压恶化或药物治疗不耐受;
(2)单功能肾或双侧肾动脉狭窄合并肾功能不全;
(3)单功能肾或双侧肾动脉狭窄肾功能恶化;
(4)一过性肺水肿;
(5)不稳定性心绞痛。

3、相对禁忌证

(1)患肾长径≤7 cm;
(2)尿液分析发现大量蛋白(≥2+)。
(3)血肌酐≥ 3.0 mg/dl。
(4)患肾估算肾小球滤过率≤10 ml/(min·1.73 m2)。
(5)肾内动脉阻力指数≥0.8。
(6)超声、CT血管造影或磁共振成像显示肾实质有大片无灌注区。

4、首选方法为经皮介入治疗。

5、血管外科直视手术仅适用于某些特殊情况:病变不适合行介入治疗,病变肾动脉附近腹主动脉需要外科重建,介入治疗失败的补救措施,对比剂严重过敏,服用抗血小板药物有禁忌等。

6、肾血管重建疗效判断:

( 1)解剖成功:经皮球囊成形术后病变肾动脉直径残余狭窄<50%,或支架术后残余狭窄<30%。
(2)血流动力学成功:狭窄前后跨病变压差收缩压<20mmHg, 平均压<10 mmHg。
(3)临床成功(疗效至少维持6 个月后才能作出临床评估):
① 血压标准:治愈:不用降压药,血压<140/90mmHg; 改善:需保持手术前的降压药,或减少降压药种类和剂量后,血压较术前下降>10%;无效:血压无变化或下降但未达到上述目标;
② 肾功能标准:GFR 提高、稳定或下降速度明显减慢,其他参考指标包括血清肌酐、胱抑素、24 h 尿蛋白改善;
心血管结局标准:心脑血管事件风险下降。

六、动脉粥样硬化性肾动脉狭窄
1、诊断包括至少1个动脉粥样硬化的危险因素,和至少两项动脉粥样硬化的影像学表现。
2、药物治疗主要针对危险因素治疗,包括戒烟、降脂、控制血压,抗血小板和降糖治疗等,重点是降脂治疗,目标为LDL-C≤1.80 mmol/L。
3、以控制高血压为目的的肾动脉支架术,入选患者需满足二个关键点:(1)肾动脉狭窄≥ 70%,且能证明狭窄与血压升高存在因果关系。(2)顽固性高血压或不用降压药高血压达Ⅲ级水平。

七、大动脉炎性肾动脉狭窄
1、诊断采用阜外诊断标准,需满足以下三项,每项须符合其中至少一条:(1)发病年龄<40 岁,女性多见;(2)具有血管受累部位的症状和(或)体征;(3)双功能超声检查、CT血管成像、核磁共振成像或者肾动脉造影发现特征性的病变影像。
2、药物治疗:非活动期是否需要抗炎治疗,有较大争议;活动期尤其急性期,一般主张积极抗炎治疗,多数指南推荐初始治疗为糖皮质激素。
3、非粥样硬化性肾动脉狭窄血管重建:大多数发病年龄在40岁前,如果肾动脉直径狭窄≥ 50%,伴有持续高血压Ⅱ级或以上,依赖降压药,则单纯肾血管性高血压的诊断基本确立,应该接受肾动脉血管重建治疗,以免长期高血压的不良影响。一般首选经皮球囊成形术,不提倡使用血管内支架。

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