缬沙坦在慢性肾脏病急性加重伴恶性高血压患者中长期治疗效果观察

发布时间：2018-03-09 08:32

本文选题：缬沙坦　切入点：慢性肾脏病急性加重　出处：《青岛大学》2017年硕士论文　论文类型：学位论文

【摘要】：目的:探讨血管紧张素II受体拮抗剂缬沙坦在治疗慢性肾脏病急性加重期并恶性高血压患者的临床疗效及安全性方法:在2012年12月至2016年12月青岛大学医学院附属医院肾内科住院患者中,筛选出符合慢性肾脏病急性加重伴恶性高血压诊断的,且随访时间达到4个月及以上的患者24例,对其进行回顾性分析研究。选用缬沙坦并联合其他降压药物治疗控制血压,缬沙坦初始剂量80-160mg/d,最大剂量320mg/d,血压控制目标设定为140/90mm Hg。达到治疗量后,比较患者治疗前及治疗后2周、4周、8周、4月的血压、血肌酐、24h尿蛋白、血红蛋白、血钾等指标的变化情况,观察缬沙坦在治疗慢性肾脏病急性加重期并恶性高血压患者的临床疗效及安全性。结果:所收集病例中,原发病为慢性肾小球肾炎继发恶性高血压10例,原发性恶性高血压并肾损害12例,糖尿病性肾病继发恶性高血压2例;其中符合溶血尿毒综合征诊断标准者5例。采集上述患者治疗前及治疗后2周末、4周末、8周末、4月末的血肌酐、尿素氮、尿蛋白、血钾、血红蛋白、血小板、血钠、血氯、血二氧化碳结合力等指标。治疗后血红蛋白、血小板等指标均明显改善,与治疗前相比,P0.05,具有统计学意义。电解质方面,其中4例患者在治疗后2-4周出现血钾轻度升高,经限制高钾饮食、间断应用利尿剂等治疗措施4-8周后稳定在正常水平;其中8例患者治疗前存在代谢性酸中毒,给予纠酸药物后均在治疗后2周达到并稳定在正常水平;血钠、血氯水平与治疗前比较均无显著变化,P0.05,不具有统计学意义;观察患者血压,参考血压控制目标判断血压控制率。结果显示第2周末时血压控制率不足3.8%(1/26),血压下降平均水平与治疗前对比,P0.05,有统计学意义;第4周末时血压控制率不足7.7%(2/26),血压下降平均水平与治疗前对比,P0.05,有统计学意义;第8周末时收缩压控制率为54.2%(13/24),舒张压控制率为45.8%(11/24),血压下降平均水平与治疗前比,P0.05,有统计学意义;第4月末时收缩压控制率为50.0%(12/24),血压下降平均水平与治疗前比,P0.05,有统计学意义,与治疗8周末比,P0.05,无统计学意义;第4月末时舒张压控制率为41.7%(10/24),血压下降平均水平与治疗前比,P0.05,有统计学意义,与治疗8周末比,P0.05,无统计学意义。观察患者尿蛋白,参考尿蛋白下降水平判断控制率,并通过个体化分析,对比缬沙坦为基础的治疗方案对不同原发病患者的疗效。结果显示治疗第2周末及之后与治疗前相比,整体尿蛋白水平有明显下降,P0.05,有统计学差异,其中原发病为糖尿病性肾病组无明显下降,P0.05,无统计学意义,原发病为恶性高血压组及慢性肾小球肾炎组有明显下降,P0.05,有统计学意义。观察患者血肌酐、尿素氮,参考下降水平判断疗效。结果显示治疗第8周末及之后血肌酐、尿素氮下降水平与治疗前相比,P0.05,有统计学差异;安全性分析:收集病例中患者在治疗过程中,4例在治疗后2-4周出现血钾轻度升高,经限制高钾饮食、间断应用利尿剂等治疗措施4-8周后稳定在正常水平,2例患者出现一过性头晕,1例患者自觉口腔金属味,其余均未发生高血钾、血肌酐病理性升高、头晕、头痛、恶心、咳嗽等不良反应。结论:1.慢性肾脏病急性加重并恶性高血压患者,ARB类药物缬沙坦较为安全按,但若达到降压目标,必须在缬沙坦基础上联合其他降压药物,但降压效果与联合药物数量无显著关系;2.缬沙坦可通过控制血压、蛋白尿等,达到去除急性加重因素、改善肾功能的作用;3.缬沙坦通过血流动力学非血流动力学效应发挥肾脏保护作用;4.ARB类药物较ACEI类药物具有更好地依从性;5.不同原发病人群应用缬沙坦为基础的治疗方案,转归不同,其中原发性恶性高血压、原发性肾小球肾炎优于糖尿病性肾病。
[Abstract]:Objective: To investigate the effect of angiotensin II receptor antagonist valsartan on the clinical efficacy and safety of treatment of chronic kidney disease and acute exacerbation in patients with malignant hypertension: from December 2012 to December 2016 in the Affiliated Hospital of Medical College of Qiingdao University Department of Nephrology inpatients, selected in line with the diagnosis of malignant hypertension with acute exacerbation of chronic kidney disease, and the follow-up period to the patients in 4 months and more than 24 of the cases were analyzed retrospectively. The combined valsartan and other antihypertensive drugs to control blood pressure, initial dose of valsartan 80-160mg/d, maximum dose of 320mg/d, blood pressure control target set for 140/90mm Hg. reach the treatment amount, compared with 2 weeks before and after treatment for 4 weeks, 8 April week, blood pressure, serum creatinine, 24h urine protein, hemoglobin, changes of serum potassium and other indicators, observe the effect of valsartan in the treatment of chronic kidney disease with acute exacerbation And the clinical efficacy and safety in patients with malignant hypertension. Results: the collected cases, as the primary disease secondary to chronic glomerulonephritis in 10 cases of malignant hypertension, primary malignant hypertension and renal damage in 12 cases, 2 cases of diabetic nephropathy with malignant hypertension; 5 cases with hemolytic uremic syndrome diagnosis criteria. Acquisition the patients before treatment and 2 weeks after treatment, 4 weeks, 8 weeks, 4 at the end of the serum creatinine, urea nitrogen, urinary protein, serum potassium, hemoglobin, platelet, blood sodium, blood serum chloride, carbon dioxide combining power. The indexes of blood red protein after treatment, platelet indexes were significantly improved, compared to with P0.05 before treatment, with statistical significance. The electrolyte, including 4 patients in 2-4 weeks after treatment blood potassium increased slightly, by limiting high potassium diet, intermittent diuretic treatment after 4-8 weeks of stability in normal level; in the treatment of 8 cases The existence of metabolic acidosis, give correct acid drugs in 2 weeks after the treatment reached and stabilized at the normal level; the blood sodium, blood chlorine levels before treatment had no significant change, P0.05, was not statistically significant; observation of blood pressure, blood pressure control reference target judgment rate of blood pressure control. The results showed that second weekend when the blood pressure control rate of less than 3.8% (1/26), average blood pressure decreased compared with before treatment, P0.05, have statistical significance; at the end of the fourth week the blood pressure control rate of less than 7.7% (2/26), average blood pressure decreased compared with before treatment, P0.05, have statistical significance; at the end of the eighth week systolic blood pressure control rate was 54.2% (13/24) diastolic blood pressure, control rate was 45.8% (11/24), average blood pressure decreased compared with that before treatment, P0.05, have statistical significance; at the end of fourth when the systolic blood pressure control rate was 50% (12/24), average blood pressure decreased compared with that before treatment, P0.05 was statistically significant, P0.05 and 8 weeks of treatment, and no statistical significance; fourth end diastolic blood pressure control rate was 41.7% (10/24), average blood pressure decreased compared with that before treatment, with statistical significance, P0.05, P0.05 and 8 weeks of treatment, and no statistical significance. The observation of urinary protein, decreased urine protein levels to determine the control reference rate, and through individual analysis, treatment scheme comparison of valsartan based on the therapeutic effects of different primary disease patients. The results showed that after second week of treatment and compared with before treatment, the urine protein level decreased significantly, P0.05, have statistical differences, the primary disease of diabetic nephropathy group decreased significantly, P0.05. No statistically significant, malignant hypertension group and chronic glomerulonephritis group protopathy was decreased significantly, P0.05, have statistical significance. Observation of serum creatinine, urea nitrogen, decreased the level of reference to determine efficacy. Results showed that eighth weeks of treatment At the end of and after the blood creatinine and urea nitrogen levels decreased compared with before treatment, P0.05, there were significant differences; safety analysis: patients were collected in the course of treatment, 4 cases in 2-4 weeks after treatment, blood potassium increased slightly, by limiting high potassium diet, intermittent application of diuretics treatment measures after 4-8 weeks of stability at the normal level, 2 patients had dizziness, 1 cases of oral metallic taste, others were not have pathological hyperkalemia, serum creatinine increased, dizziness, headache, nausea, cough and other adverse reactions. Conclusion: 1. patients with acute exacerbation of chronic kidney disease in patients with malignant hypertension, ARB drug valsartan is safe according to the but, if to achieve goal, must be based on the combination of valsartan and other antihypertensive drugs, but the number of antihypertensive effect and no significant relationship between the 2. drug combination; valsartan can control the blood pressure, urine protein, to remove the acute aggravated factors, improve Renal function; 3. valsartan by hemodynamic non hemodynamic effects play a role in renal protection; 4.ARB drugs is ACEI drugs have better treatment compliance; 5., the incidence of different populations of valsartan based outcome, including primary malignant hypertension, primary glomerulonephritis than diabetic nephropathy.

【学位授予单位】：青岛大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R544.1;R692

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