Multicenter assessment of hypertension management among liver transplantation recipients.
Multicenter assessment of hypertension management among liver transplantation recipients.
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肝移植受者高血压管理的多中心评估。
DOI：
10.1002/lt.26542
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发表时间：
2023
期刊：
影响因子：
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通讯作者：
VanWagner,LisaB
中科院分区：
文献类型：
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作者：
Chebrolu,Sneha;Phipps,Meaghan;Yao,Frederick;Lai,Jennifer;Verna,Elizabeth;Serper,Marina;Cullaro,Giuseppe;Asrani,SumeetK;VanWagner,LisaB
心血管（CV）疾病是肝移植（LT）后发病率和死亡率的主要驱动因素;三分之一的LT受者（LTR）将在移植后1年内发生CV事件（CVE）。[1]在LTR中，控制血压（BP）与死亡率和CVE分别降低45%和38%相关。[ 1]虽然BP管理是改善LT结局的关键可改变风险因素，但缺乏标准化实践指南，LTR中的长期BP管理实践也没有得到很好的描述。我们旨在评估美国不同地区五个主要移植中心的BP管理实践。我们检查了2017年至2019年期间确定的共计1335例LTR（n= 293例西北大学，IL; n= 170例哥伦比亚大学，NY; n = 349例加州大学旧金山弗朗西斯科，CA; n= 398例贝勒大学医学中心，TX; n= 125例宾夕法尼亚大学，PA），随访至2020年12月31日。我们回顾了移植后高血压的病历，高血压定义为血压≥ 140/≥ 90 mm Hg或记录使用降压药物。医疗记录还用于确定治疗时使用的降压药物以及治疗开始后是否达到血压控制。血压控制定义为< 140/< 90 mm Hg，因为已证明其在LTR中的CV结局中具有显著改善。[ 1]在数据收集时，移植后电子病历中记录的最后一次可用血压用于确定患者是否患有不受控制的高血压。使用分类变量的频率计数和百分比以及连续变量的平均值±标准差描述LTR研究样本的特征。由于这项研究需要使用已经收集的数据进行研究，所有五个中心的机构审查委员会批准免于审查。总体而言，71.7%（n= 957）的患者患有LT后高血压，其中89.7%（n= 858）的患者接受了至少一种降压药物治疗。此外，61.5%的LTR处方至少两种降压药物，平均处方2.2种降压药物。总体而言，只有51.9%的LTR在使用降压药物时实现了血压控制。各机构的抗高血压药物选择差异很大（图1）。钙通道阻滞剂是最常见的处方药（59.5%），其次是选择性β受体阻滞剂（37.6%）。最少使用的降压药物是保钾利尿剂（4.9%）和噻嗪类利尿剂（3.9%）。我们的研究表明，移植后高血压是非常普遍的LTR的基础上记录的血压值作为常规临床护理的一部分。尽管处方了降压药物，但几乎一半的LTR没有达到当前普通人群高血压指南定义的充分血压控制。[ 2]值得注意的是，在当前分析中用于定义“对照”的BP阈值为< 140/90 mm Hg。来自收缩压干预试验（SPRINT）的高质量数据支持在非LTR、高心脏风险人群中更低的血压目标（例如，< 120/80 mm Hg）。[ 3]美国肝病研究协会（AASLD）的指南建议在LTR中将BP< 130/80 mm Hg作为目标，尽管没有研究支持这一建议。事实上，在最近的一项研究中，我们未能证明BP< 130/80 mm Hg与LTR中的CVES或死亡率降低相关。[1]我们还展示了…
To the editor, Cardiovascular (CV) disease is a primary driver of morbidity and mortality after liver transplantation (LT); one in three LT recipients (LTRs) will experience a CV event (CVE) within 1 year of transplantation.[1] Control of blood pressure (BP) is associated with a 45% and 38% reduction in mortality and CVEs, respectively, in LTRs.[ 1] Although BP management is a critical modifiable risk factor for improved LT outcomes, there is a lack of standardized practice guidelines and long-term BP management practices in LTRs are not well described. We aimed to assess the BP management practices at five major transplantation centers in diverse regions across the United States. We examined a total of 1335 LTRs (n= 293 Northwestern University, IL; n= 170 Columbia University, NY; n= 349 University of California San Francisco, CA; n= 398 Baylor University Medical Center, TX; and n= 125 University of Pennsylvania, PA) identified between 2017 and 2019 with follow-up through December 31, 2020. We reviewed medical records for the presence of posttransplantation hypertension, which was defined as having a BP of≥ 140/≥ 90 mm Hg or as a documented use of a BP-lowering medication. The medical records were also used to determine which BP-lowering medications were prescribed for treatment and whether BP control was achieved after initiation of treatment. BP control was defined as< 140/< 90 mm Hg because it has been shown to have a significant improvement in CV outcomes among LTRs.[ 1] The last available BP recorded in the electronic medical record after transplantation, at the time of data collection, was used to determine whether patients had uncontrolled hypertension. Characteristics of the study sample of LTRs were described using frequency counts and percentages for categorical variables and means±standard deviations for continuous variables. As the study entails research using already collected data, the institutional review board at all five centers granted exemption from review.Overall, 71.7%(n= 957) of the total number of patients had post-LT hypertension and 89.7%(n= 858) of these patients were treated with at least one BP-lowering agent. Further, 61.5% of LTRs were prescribed at least two BP-lowering medications with an average of 2.2 BP-lower medications prescribed. Overall, only 51.9% of LTRs achieved BP control while on BP-lowering medications. There was a wide variation in the choice of antihypertensive agents across institutions (Figure 1). Calcium channel blockers were the most commonly prescribed (59.5%) followed by selective beta-blockers (37.6%). The least utilized BP-lowering medications were K-sparing diuretics (4.9%) and thiazide diuretics (3.9%). Our study shows that posttransplantation hypertension is highly prevalent among LTRs based on BP values recorded as part of routine clinical care. Despite being prescribed BP-lowering medications, almost half of the LTRs did not achieve adequate BP control as defined by current hypertension guidance in the general population.[ 2] Notably, the BP threshold used to define “control” in the current analysis was< 140/90 mm Hg. High-quality data from the Systolic Blood Pressure Intervention Trial (SPRINT) support even lower BP targets (eg,< 120/80 mm Hg) in non-LTR, high cardiac risk populations.[ 3] Guidance from the American Association for the Study of Liver Diseases (AASLD) recommends targeting BP< 130/80mm Hg in LTRs, although there are no studies to support this recommendation. In fact, in a recent work, we failed to demonstrate that BP< 130/80 mm Hg was associated with a reduction in CVEs or mortality in LTRs.[1] We also showed …