高血压和高尿酸如何在治疗中兼顾.ppt

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level,Fifth level,Presentation title,Date,*,高血压和高尿酸,如何在治疗中兼顾？,病例描述,-,患者基本情况,患者男性，,55,岁，已婚。,五个月前体检过程中，,发现,血尿酸,456.4umol/L,，,血肌酐升高,达,231 umol/L，尿素氮13.37mmol/L,，同时伴,尿蛋白+,，尿潜,血+,。,患者,1,年前诊断患有高血压。平日血压最高可达,180/100 mmHg,。,曾间断服用卡托普利、复方利血平等,降压药,，,但,血压控制,不稳定。,患者,2,年前曾患肾小球肾炎，经当地医院治愈后出院。具体病情程度和治疗不详。,否认,有,遗传,性,高血压家族史和痛风家族史。,患者自述：因工作需要，每日吸烟,20,支左右；每周饮酒,3-4,次，每次,1-2,斤左右。,病例描述：,体格检查及相关实验室检查结果,身高,：,178 cm,体重,：,80 kg,BMI,：,26 kg/m2,血压,：,162/97 mmHg,心率,：律齐，,80,次,/,分,基本体格检查结果,实验室检查异常结果,检验项目,结果,血红蛋白,(HGB),12.6 g/L,甘油三酯,(TG),3.01 mmol/L,总胆固醇,(TC),5.12 mmol/L,血清尿酸,(UA),467 umol/L,肌酐,(Cr),286 umol/L,尿素氮,(BUN),9.7 mmol/L,24,小时尿蛋白定量,1956 mg/24h,肾脏超声,检查报告,：,双侧肾脏大小、位置及形态均未见异常；,左肾,82*38mm,，,右肾,75*38mm,；,同位素肾图显示：,双肾血流灌注减低,；,双肾弥漫性病变伴轻度萎缩,；,肾小球滤过率,(GFR),：,31.5 ml/min,。其中,左肾,14.7 ml/min,，,右肾,16.8ml/min,。,双侧,眼底,及视野,检查：,未见异常。,病例描述：其他特殊检查,临床诊断及思路,/,依据,根据患者的既往病史及当前检查结果，明确以下三项临床诊断。包括：,高血压,2,级,中度,高尿酸血症,慢性肾小球肾炎,高血压和高尿酸血症相互影响,肾小球滤过率,肾小管重吸收,肾小管分泌,血乳酸盐,酮症,高血压,利尿剂治疗,血容量进一步,尿酸排泄,高尿酸血症,刺激肾素分泌,激活肾素,-,血管紧张素系统,抑制,NO,合成酶,动脉平滑肌细胞增生导致高血压,Mazzali M,et al.Hypertension 2001,2013ESC,指南对尿酸的描述,尿酸是否是心血管疾病的危险因素尚无定论,目前无一指南将尿酸列为心血管疾病的危险因素,痛风是利尿剂使用的禁忌症，无论尿酸是否增高,高尿酸血症不一定是利尿剂使用的禁忌症,问题二：选择何种治疗原则,先降压,先降尿酸,B.,降压同时关注尿酸水平,高尿酸血症治疗流程,无症状高尿酸血症合并心血管疾病诊治中国专家共识,高尿酸血症,有痛风发作,或痛风结节,无痛风发作但,合并心血管危险因素,无痛风发作无心血管危险因素,420-480,umol/L,480umol/L,以上,420-540,umol/L,540umol/L,以上,药物治疗,+,生活指导,短期生活指导,无效，药物治疗,药物治疗,+,生活指导,生活指导,无效药物治疗,药物治疗,+,生活指导,心血管危险因素包括：,高血压、糖耐量异常或糖尿病、高脂血症、代谢综合征、冠心病、脑卒中、心力衰竭、肾功能异常。,*,应用厄贝沙坦,12,个月，,患者收缩压,/,舒张压显著改善,与基线相比：,*,P,0.05,*,P,0.01,*,P,0.001,收缩压,舒张压,Clin Pharmacol.2014 6 79 86,本例患者治疗原则,治疗原则：,降压，同时关注患者尿酸水平。,具体治则：,(1),降压：慢性肾脏病,患者血压控制目标,为,24,小时尿蛋白,1g/d,，血压控制在,125/75mmHg,以下,(2),控制蛋白尿,0.5g/24h,(,当前,患者,24h,尿蛋白定量为,1956mg),问题三：选择何种药物治疗,血管紧张素受体拮抗剂,(ARB),促尿酸排泄剂,血管紧张素受体拮抗剂,(ARB),联合促尿酸排泄剂,本例患者治疗效果,治疗前,治疗10天,治疗30天随访,血压,162/97mmHg,121/70mmHg,126/75mmHg,尿蛋白定量,1956 mg/24h,954mg/24h,-,尿酸,467umol/L,416umol/L,319umol/L,尿素氮,9.7mmol/L,7.10mol/L,6.40mol/L,肌酐,286umol/L,216umol/L,193umol/L,治疗体会,对于伴有高尿酸血症的高血压患者来说，应避免选择影响尿酸生成和排泄的降压药，以免加重高尿酸血症或痛风；,高血压合并高尿酸血症的治疗策略，应同时关注降压及肾脏保护两方面。单纯尿酸升高而未出现痛风的患者，可以考虑使用血管紧张素,II,受体拮抗剂,(ARB);,厄贝沙坦在降压的同时，还能一定程度上降低患者的血尿酸水平。其机制可能与血管紧张素,II,受体的阻断作用，能有效改善肾脏血流量，减少尿蛋白排泄，从而对肾脏起到一定程度的保护作用。,