临床经验:高血压性肾脏病,这些你要GET!

2017-03-18 李青 李青大夫

与高血压相关的心、脑、肾疾病已经成为我国居民最主要的死亡原因。和心、脑损伤相比,肾脏受损后常常没有明显的症状,所以肾脏病经常被忽视。由高血压导致的肾脏病称高血压性肾脏病,是导致终末期肾脏病(尿毒症)的重要原因,据美国统计,在导致尿毒症的病因中,高血压性肾脏病约占28.4%,仅次于糖尿病肾病占第二位。而我国的相应数据为17%(来自于侯凡凡院士的统计),紧随肾小球肾炎和糖尿病肾病之后占到第三位。高血压



高血压相关的心、脑、肾疾病已经成为我国居民最主要的死亡原因。和心、脑损伤相比,肾脏受损后常常没有明显的症状,所以肾脏病经常被忽视。

高血压导致的肾脏病称高血压性肾脏病,是导致终末期肾脏病(尿毒症)的重要原因,据美国统计,在导致尿毒症的病因中,高血压性肾脏病约占28.4%,仅次于糖尿病肾病占第二位。而我国的相应数据为17%(来自于侯凡凡院士的统计),紧随肾小球肾炎和糖尿病肾病之后占到第三位。

高血压对肾脏主要损害肾小球和肾小管,一般而言,久不控制的高血压,5年时间就会出现肾损伤。肾小管对缺血最敏感,所以高血压性肾脏病最早出现肾小管浓缩功能障碍,临床表现为夜尿增多,晚上总起夜。夜间(晚8点至早8点)尿量超过全天尿量的1/3即为夜尿增多。夜尿增多是高血压性肾脏病早期特征性症状,但遗憾的是常常被忽视。

如果病情持续发展,一半以上的肾小球发生硬化,血肌酐就会升高,意味着肾脏受损到比较严重的程度。高血压性肾脏病也有蛋白尿,但尿蛋白定量一般不超过1g/天,可以出现血尿。此外,视网膜动脉和肾小球病变相一致,所以,高血压性肾脏病还常常伴有视网膜动脉硬化。

常见的肾脏病,比如肾小球肾炎、糖尿病肾病等,大都是先出现蛋白尿,然后再出现血肌酐升高。而高血压性肾脏病比较另类,许多患者直到血肌酐升高了尿蛋白都可能正常。这种另类的表现更加重了它的隐蔽性。

控制血压是对高血压性肾脏病最好的治疗。普通高血压患者,血压的控制目标是140/90mmHg以下,而高血压性肾脏病,为了肾脏保护,血压的控制目标更加严格,一般130/80mmHg以下,这就需要联合用药。

首选的降压药为对肾脏有保护作用的普利类或者沙坦类降压药(二者只能选其一),而且往往需要2倍以上的剂量,同时联合长效地平类降压药。此外,根据高血压的原因或者其他器官的损伤情况,再联合使用其他降压药。比如,容量依赖性高血压用氢氯噻嗪,原发性醛固酮增多症导致的继发性高血压用螺内酯,出现心脏并发症的用β受体阻断剂等。

早期降压并控制达标是高血压性肾脏病预防的关键。

5年以上的高血压,如果出现下列情况,高度怀疑高血压性肾脏病。但应注意,一些患者不查体,高血压病史可能不准确。

1、夜尿增多;

2、少量蛋白尿;

3、视网膜动脉硬化;

4、能排除其他的肾脏病。

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    2017-04-27 1e145228m78(暂无匿称)

    学习了,谢谢作者分享!

    0

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    2017-04-26 laymankey

    感谢分享一下!

    0

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    2017-03-19 飛歌

    学习了,很有用

    0

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