NEJM:氯噻酮治疗晚期慢性肾病患者高血压的疗效如何?

2021-12-30 MedSci原创 MedSci原创

在晚期慢性肾病和控制不佳的高血压患者中,与安慰剂相比,氯噻酮治疗在12周时改善了血压控制。

几乎没有证据支持使用噻嗪类利尿剂治疗晚期慢性肾病患者的高血压

近日,顶级医学期刊NEJM上发表了一篇研究文章,研究人员将4期慢性肾病和高血压控制不佳的患者(经24小时动态血压监测证实)以1:1的比例随机分配接受氯噻酮,初始剂量为每天12.5mg,每4周增加一次剂量,如果需要,最大剂量为每天50mg,或安慰剂治疗;根据先前使用袢利尿剂对随机化进行分层。

该研究的主要结局是24小时动态收缩压从基线到12周的变化水平。该研究的次要结局是尿白蛋白与肌酐比值、B型利钠肽前体N末端水平、血浆肾素和醛固酮水平以及总体积从基线到12周的变化。研究人员还评估了其安全性。

该研究共有160名患者接受了随机分组,其中121名(76%)患有糖尿病,96名(60%)正在接受袢利尿剂治疗。在基线时,平均(±SD)估计的肾小球滤过率为每1.73平方米体表面积为23.2±4.2ml/min,接受抗高血压药物治疗的患者平均数量为3.4±1.4ml/min。随机分组时,氯噻酮组的平均24小时动态收缩压为142.6±8.1mmHg,安慰剂组为140.1±8.1mmHg,平均24小时动态舒张压分别为74.6±10.1mmHg和72.8±9.3mmHg。氯噻酮组24小时收缩压从基线到12周的调整后变化为-11.0mmHg(95%置信区间[CI]为-13.9至-8.1),在安慰剂组为-0.5mmHg(95%CI为-3.5到2.5),组间差异为-10.5mmHg(95%CI为-14.6至-6.4)(P<0.001)。氯噻酮组尿白蛋白与肌酐比值从基线到12周的百分比变化比安慰剂组低50个百分点(95%CI为37至60)。与安慰剂组相比,氯噻酮组发生低钾血症、血清肌酐水平可逆性升高、高血糖、头晕和高尿酸血症的发生频率更高。

由此可见,在晚期慢性肾病和控制不佳的高血压患者中,与安慰剂相比,氯噻酮治疗在12周时改善了血压控制。

原始出处:
 
Rajiv Agarwal,et al.Chlorthalidone for Hypertension in Advanced Chronic Kidney Disease.NEJM.2021.https://www.nejm.org/doi/full/10.1056/NEJMoa2110730

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