BLOOD-PRESSURE CONTROL, PROTEINURIA, AND THE PROGRESSION OF RENAL-DISEASE - THE MODIFICATION OF DIET IN RENAL-DISEASE STUDY
BLOOD-PRESSURE CONTROL, PROTEINURIA, AND THE PROGRESSION OF RENAL-DISEASE - THE MODIFICATION OF DIET IN RENAL-DISEASE STUDY
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DOI：
10.7326/0003-4819-123-10-199511150-00003
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发表时间：
1995-11-15
影响因子：
39.2
通讯作者：
SEIFTER, JL
中科院分区：
文献类型：
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作者：
PETERSON, JC;ADLER, S;SEIFTER, JL
目标：在肾脏疾病饮食改良研究中，检查蛋白尿、处方血压和实际血压以及肾小球滤过率下降之间的关系。设计：2项随机试验，在不同原因的慢性肾脏疾病患者中进行。在大学医院设置15个门诊肾脏病实践。患者：840例患者，其中585例在研究A中（肾小球滤过率，25至55 mL/min 1. 73 m（2）），255例在研究B中（肾小球滤过率，13至24 mL/min。1.73 m（2））。需要胰岛素的糖尿病患者被排除在外。患者被随机分配到通常的血压目标（目标平均动脉压，≤ 60岁患者≤ 107 mm Hg，≤ 61岁患者≤ 113 mm Hg）或低血压目标（目标平均动脉压，小于或等于60岁的患者小于或等于92 mm Hg，小于或等于61岁的患者小于或等于98 mm Hg）。主要结果测量：随访期间肾小球滤过率下降率和蛋白尿变化。在研究A（P = 0.02）和研究B（P = 0.01）中，低巢压目标对基线蛋白尿较高的人有更大的有益作用。在研究A（r = -0.20; P < 0.001）和研究B（r = -0.34; Pt 0.001）中，随访期间，高血压患者的肾小球滤过率下降更快，并且这些相关性在基线蛋白尿较高的患者中更强（研究A中P < 0.001;研究B中P < 0.01）。在研究A中，肾小球滤过率下降和随访血压之间的相关性是非线性的（P = 0.011），并且在平均动脉压较高时更强。在这两项研究中，低血压目标在随机分组后的前4个月内显著降低了蛋白尿。反过来，这与随后的下降较慢，肾小球滤过率。结论：我们的研究支持蛋白尿是一个独立的危险因素的肾脏疾病的进展的概念。对于蛋白尿超过1 g/d的患者，我们建议目标血压低于92 mm Hg（125/75 mm Hg）。对于蛋白尿为0.25 - 1.0 g/d的患者，建议目标平均动脉压低于98 mm Hg（约130/80 mm Hg）。降低血压减少蛋白尿的程度可能是衡量这种疗法在减缓肾脏疾病进展方面的有效性的一个指标。
Objective: To examine the relations among proteinuria, prescribed and achieved blood pressure, and decline in glomerular filtration rate in the Modification of Diet in Renal Disease Study.Design: 2 randomized trials in patients with chronic renal diseases of diverse cause.Setting 15 outpatient nephrology practices at university hospitals.Patients: 840 patients, of whom 585 were in study A (glomerular filtration rate, 25 to 55 mL/min 1.73 m(2)) and 255 were in study B (glomerular filtration rate, 13 to 24 mL/min . 1.73 m(2)). Diabetic patients who required insulin were excluded.Interventions : Patients were randomly assigned to a usual blood pressure goal (target mean arterial pressure, less than or equal to 107 mm Hg for patients less than or equal to 60 years of age and less than or equal to 113 mm Hg for patients less than or equal to 61 years of age) or a low blood pressure goal (target mean arterial pressure, less than or equal to 92 mm Hg for patients less than or equal to 60 years of age and less than or equal to 98 mm Hg for patients less than or equal to 61 years of age).Main Outcome Measures: Rate of decline in glomerular filtration rate and change in proteinuria during follow-up.Results: The low brood pressure goal had a greater beneficial effect in persons with higher baseline proteinuria in both study A (P = 0.02) and study B (P = 0.01). Glomerular filtration rate declined faster in patients with higher achieved blood pressure during follow-up in both study A (r = -0.20; P < 0.001) and study B (r = -0.34; Pt 0.001), and these correlations were stronger in persons with higher baseline proteinuria (P < 0.001 in study A; P < 0.01 in study B). In study A, the association between decline in glomerular filtration rate and achieved follow-up blood pressure was nonlinear (P = 0.011) and was stronger at higher mean arterial pressure. in both studies, the low blood pressure goal significantly reduced proteinuria during the first 4 months after randomization. This, in turn, correlated with a slower subsequent decline in glomerular filtration rate.Conclusions: Our study supports the concept that proteinuria is an independent risk factor for the progression of renal disease. For patients with proteinuria of more than 1 g/d, we suggest a target blood pressure of less then 92 mm Hg (125/75 mm Hg). For patients with proteinuria of 0.25 to 1.0 g/d, a target mean arterial pressure of less than 98 mm Hg (about 130/80 mm Hg) may be advisable. The extent to which lowering blood pressure reduces proteinuria may be a measure of the effectiveness of this therapy in slowing the progression of renal disease.