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Dialyse aktuell 2016; 20(09): 450-454
DOI: 10.1055/s-0042-118943
Dialyse
© Georg Thieme Verlag Stuttgart · New York

Blutdruckeinstellung und -medikation

Wie beeinflussen sie das Langzeitüberleben von Dialysepatienten?Blood pressure control and antihypertensive treatment – How do they influence long-term survival of dialysis patients?
Martin Hausberg
1   Medizinische Klinik I, Städtisches Klinikum Karlsruhe (Klinikdirektor: Prof. Dr. Martin Hausberg)
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Publication Date:
21 November 2016 (online)

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Patienten mit terminaler Niereninsuffizienz weisen eine deutlich erhöhte kardiovaskuläre Morbidität und Sterblichkeit auf. Die Ursachen hierfür sind multifaktoriell, wesentlich sind erhebliche Schädigungen der arteriellen Gefäße. Die bei einem großen Teil der Dialysepatienten prävalente arterielle Hypertonie trägt zu der hohen kardiovaskulären Komplikationsrate bei. Wegen der ausgeprägten Alterationen des kardiovaskulären Systems bei Dialysepatienten besteht eine U-förmige Beziehung zwischen Blutdruck vor Dialyse und kardiovaskulärer Komplikationsrate. Blutdruckwerte zwischen 140 und 160 mmHg systolisch vor Dialysebeginn sind mit der geringsten kardiovaskulären Komplikationsrate bei Dialysepatienten assoziiert. Für die Blutdruckkontrolle und die kardiovaskuläre Prognose entscheidend ist die konsequente Einstellung der Patienten auf das Trockengewicht. Darüber hinaus sind bei vielen Patienten Antihypertensiva erforderlich. Es ist bislang nicht definitiv geklärt, ob gewisse Klassen von Antihypertensiva wie z. B. Hemmstoffe des Renin-Angiotensin-Aldosteron-Systems Vorteile gegenüber anderen Klassen von Antihypertensiva haben in Bezug auf die kardiovaskuläre Prognose.

Patients with end-stage renal disease suffer from seriously increased cardiovascular morbidity and mortality. The increased incidence of cardiovascular complications is multifactorial, mainly explained by severe alterations of the arterial wall and the myocardium. Arterial hypertension is prevalent in a large proportion of dialysis patients and contributes to the elevated rate of cardiovascular complications. Because of severe alterations of arterial structure and function, there is a U-shaped relationship between predialysis blood pressure and the incidence of cardiovascular complications. The optimal systolic blood pressure before dialysis appears to be between 140 and 160 mmHg. The most important measures to achieve target blood pressure in dialysis patients consist of probing dry weight and maintaining dietary salt restriction. Many patients need in addition antihypertensive treatment. It is still not established, whether certain classes of antihypertensive drugs, e. g. inhibitors of the renin-angiotensin-aldosterone system, are more advantageous with respect to cardiovascular prognosis of dialysis patients than other classes of antihypertensive drugs.

Key words

dialysis - end-stage renal disease - arterial hypertension - target blood pressure - antihypertensive treatment - cardiovascular complications
 

  • Literatur

  • 1 Barenbrock M, Spieker C, Laske V et al. Studies of the vessel wall properties in hemodialysis patients. Kidney Int 1994; 45: 1397-1400
    CrossrefGoogle Scholar
  • 2 Kosch M, Barenbrock M, Kisters K et al. Relationship between muscle sympathetic nerve activity and large artery mechanical vessel wall properties in renal transplant patients. J Hypertens 2002; 20: 501-508
    CrossrefGoogle Scholar
  • 3 Hausberg M, Kosch M, Harmelink P et al. Sympathetic nerve activity in end-stage renal disease. Circulation 2002; 106: 1974-1979
    CrossrefPubMedGoogle Scholar
  • 4 Guerin AP, Blacher J, Pannier B et al. Impact of aortic stiffness attenuation on survival of patients in end-stage renal failure. Circulation 2001; 103: 987-992
    CrossrefPubMedGoogle Scholar
  • 5 Port FK, Hulbert-Shearon TE, Wolfe RA et al. Predialysis blood pressure and mortality risk in a national sample of maintenance hemodialysis patients. Am J Kidney Dis Off J Natl Kidney Found 1999; 33: 507-517
    CrossrefGoogle Scholar
  • 6 Chang TI, Friedman GD, Cheung AK et al. Systolic blood pressure and mortality in prevalent haemodialysis patients in the HEMO study. J Hum Hypertens 2011; 25: 98-105
    CrossrefGoogle Scholar
  • 7 Lacson Jr E, Lazarus JM. The association between blood pressure and mortality in ESRD-not different from the general population?. Semin Dial 2007; 20: 510-517
    CrossrefGoogle Scholar
  • 8 Dasselaar JJ, Slart RHJA, Knip M et al. Haemodialysis is associated with a pronounced fall in myocardial perfusion. Nephrol Dial Transplant 2008; 24: 604-610
    CrossrefGoogle Scholar
  • 9 Agarwal R. Blood Pressure and Mortality Among Hemodialysis Patients. Hypertension 2010; 55: 762-768
    CrossrefGoogle Scholar
  • 10 Bansal N, McCulloch CE, Rahman M et al. CRIC Study Investigators. Blood pressure and risk of all-cause mortality in advanced chronic kidney disease and hemodialysis: the chronic renal insufficiency cohort study. Hypertension 2015; 65: 93-100
    CrossrefGoogle Scholar
  • 11 Agarwal R. Pro: Ambulatory blood pressure should be used in all patients on hemodialysis. Nephrol Dial Transplant 2015; 30: 1432-1437
    CrossrefGoogle Scholar
  • 12 Jardine AG. Con: Ambulatory blood pressure measurement in patients receiving haemodialysis: a sore arm and a waste of time?. Nephrol Dial Transplant 2015; 30: 1438-1441
    CrossrefGoogle Scholar
  • 13 Shafi T, Sozio SM, Bandeen-Roche KJ et al. DEcIDE Network Patient Outcomes in End Stage Renal Disease Study Investigators. Predialysis systolic BP variability and outcomes in hemodialysis patients. J Am Soc Nephrol 2014; 25: 799-809
    CrossrefGoogle Scholar
  • 14 Denker MG, Cohen DL. Antihypertensive Medications in End-Stage Renal Disease. Semin Dial 2015; 28: 330-336
    CrossrefGoogle Scholar
  • 15 Heerspink HJL, Ninomiya T, Zoungas S et al. Effect of lowering blood pressure on cardiovascular events and mortality in patients on dialysis: a systematic review and meta-analysis of randomised controlled trials. Lancet 2009; 373: 1009-1015
    CrossrefGoogle Scholar
  • 16 Inrig JK. Antihypertensive agents in hemodialysis patients: a current perspective. Semin Dial 2010; 23: 290-297
    CrossrefGoogle Scholar
  • 17 Siddiqi L, Blankestijn PJ. Sympathetic Activity and Clinical Outcome in Dialysis Patients. Hypertension 2009; 54: e8
    CrossrefGoogle Scholar
  • 18 Hausberg M, Tokmak F, Pavenstädt H, Krämer B, Rump L. Effects of moxonidine on sympathetic nerve activity in patients with end-stage renal disease. J Hypertens 2010; 28: 1920-1927
    CrossrefGoogle Scholar
  • 19 Zannad F, Kessler M, Lehert P et al. Prevention of cardiovascular events in end-stage renal disease: results of a randomized trial of fosinopril and implications for future studies. Kidney Int 2006; 70: 1318-1324
    CrossrefGoogle Scholar
  • 20 Cice G, Di Benedetto A, D’Isa S et al. Effects of telmisartan added to Angiotensin-converting enzyme inhibitors on mortality and morbidity in hemodialysis patients with chronic heart failure a double-blind, placebo-controlled trial. J Am Coll Cardiol 2010; 56: 1701-1708
    CrossrefGoogle Scholar
  • 21 Iseki K, Arima H, Kohagura K et al. Olmesartan Clinical Trial in Okinawan Patients Under OKIDS (OCTOPUS) Group. Effects of angiotensin receptor blockade (ARB) on mortality and cardiovascular outcomes in patients with long-term haemodialysis: a randomized controlled trial. Nephrol Dial Transplant 2013; 28: 1579-1589
    CrossrefGoogle Scholar
  • 22 Agarwal R, Sinha AD, Pappas MK et al. Hypertension in hemodialysis patients treated with atenolol or lisinopril: a randomized controlled trial. Nephrol Dial Transplant 2014; 29: 672-681
    CrossrefGoogle Scholar
  • 23 Ito Y, Mizuno M, Suzuki Y et al. Nagoya Spiro Study Group. Long-term effects of spironolactone in peritoneal dialysis patients. J Am Soc Nephrol 2014; 25: 1094-1102
    CrossrefGoogle Scholar
  • 24 Matsumoto Y, Mori Y, Kageyama S et al. Spironolactone reduces cardiovascular and cerebrovascular morbidity and mortality in hemodialysis patients. J Am Coll Cardiol 2014; 63: 528-536
    CrossrefGoogle Scholar
  • 25 Bomback AS. Mineralocorticoid Receptor Antagonists in End-Stage Renal Disease: Efficacy and Safety. Blood Purif 2016; 41: 166-170
    CrossrefGoogle Scholar
  • 26 Weir M, Dixon S, Fleet J et al. β-Blocker dialyzability and mortality in older patients receiving hemodialysis. J Am Soc Nephrol 2015; 26: 987-996
    CrossrefGoogle Scholar
  • 27 Charra B. Fluid balance, dry weight, and blood pressure in dialysis. Hemodial Int 2007; 11: 21-31
    CrossrefPubMedGoogle Scholar
  • 28 FNH Trial Group. Chertow GM, Levin NW, Beck GJ et al In-Center Hemodialysis Six Times per Week versus Three Times per Week. N Engl J Med 2010; 363: 2287-2300
    CrossrefGoogle Scholar
  • 29 Manlucu J, Gallo K, Heidenheim PA, Lindsay RM. Lowering postdialysis plasma sodium (conductivity) to increase sodium removal in volume-expanded hemodialysis patients: a pilot study using a biofeedback software system. Am J Kidney Dis 2010; 56: 69-76
    CrossrefGoogle Scholar
  • 30 Hecking M, Karaboyas A, Rayner H et al. Dialysate sodium prescription and blood pressure in hemodialysis patients. Am J Hypertens 2014; 27: 1160-1169
    CrossrefGoogle Scholar
  • 31 Agarwal R, Alborzi P, Satyan S, Light RP. Dry-weight reduction in hypertensive hemodialysis patients (DRIP): a randomized, controlled trial. Hypertension 2009; 53: 500-507
    CrossrefGoogle Scholar
  • 32 Agarwal R, Light RP. Intradialytic hypertension is a marker of volume excess. Nephrol Dial Transplant 2010; 25: 3355-3361
    CrossrefGoogle Scholar
  • 33 Agarwal R. Hypervolemia is associated with increased mortality among hemodialysis patients. Hypertension 2010; 56: 512-517
    CrossrefGoogle Scholar
  • 34 Van Buren PN, Inrig JK. Mechanisms and Treatment of Intradialytic Hypertension. Blood Purif 2016; 41: 188-193
    CrossrefGoogle Scholar
  • 35 Van Buren P, Kim C, Toto R, Inrig J. Intradialytic hypertension and the association with interdialytic ambulatory blood pressure. Clin J Am Soc Nephrol 2011; 6: 1684-1691
    CrossrefGoogle Scholar
  • 36 Chang TI, Zheng Y, Montez-Rath ME, Winkelmayer WC. Antihypertensive Medication Use in Older Patients Transitioning from Chronic Kidney Disease to End-Stage Renal Disease on Dialysis. Clin J Am Soc Nephrol 2016; 11: 1401-1412
    CrossrefGoogle Scholar