Spironolactone for resistant hypertension in advanced chronic kidney disease-red, amber or green?
Spironolactone for resistant hypertension in advanced chronic kidney disease-red, amber or green?
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螺内酯治疗晚期慢性肾病难治性高血压——红色、琥珀色还是绿色？
DOI：
10.1093/ndt/gfz299
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发表时间：
2020
期刊：
影响因子：
--
通讯作者：
Agarwal R
中科院分区：
文献类型：
--
作者：
Agarwal R
顽固性高血压（RHTN）定义为血压（BP）仍然不受控制（欧洲指南> 140/90 mmHg，美国指南> 130/80 mmHg），尽管使用了三种最佳剂量的降压药物，包括利尿剂[1]。使用24小时动态血压监测排除白色大衣高血压，2018年的一项荟萃分析确定RHTN在一般人群中的患病率为10.8%[2]。目前的指南建议，在RHTN患者中，螺内酯应作为一线治疗添加到三种降压治疗中，这些降压治疗未能控制血压[1]。PATHWAY-2研究（螺内酯对比安慰剂、比索洛尔和多沙唑嗪，以确定耐药性高血压的最佳治疗）是一项多因素交叉试验，证明螺内酯在改善RHTN患者的血压控制方面比安慰剂和a-或b-受体阻滞剂更有效[3]。然而，PATHWAY-2研究排除了估计肾小球滤过率（eGFR）< 45 mL/min/1.73 m2的患者以及高钾血症患者。这些患者经常被肾脏病学家看到，并可能受益于盐皮质激素受体拮抗剂添加到他们的抗高血压方案。欧洲高血压学会指南不鼓励使用螺内酯，除非eGFR> 45 mL/min/1.73 m2或血清钾（K）< 4.5 mEq/L。因此，慢性肾脏疾病（CKD）患者通常拒绝使用螺内酯;此外，在一项全球调查中，CKD高血压患者使用螺内酯的比例< 1%[4]。这是不幸的，因为RHTN的患病率在晚期CKD患者中高出数倍[5]。此外，队列研究表明，RHTN与该人群的发病率和死亡率增加相关[5，6]。使用阻断盐皮质激素受体的药物与高钾血症风险增加近2倍相关[7]。在肠道中结合K的新药的开发可能允许在高风险患者中使用螺内酯。最近，Patiromer使螺内酯能够用于治疗RHTN和CKD患者（AMBER）
Resistant hypertension (RHTN) is defined as blood pressure (BP) that remains uncontrolled (> 140/90 mmHg by European guidelines and> 130/80mmHg by US guidelines), despite the use of three antihypertensive drugs in optimal doses that include a diuretic [1]. Using 24-h ambulatory BP monitoring to exclude white coat hypertension, a 2018 meta-analysis ascertained the prevalence of RHTN to be 10.8% in the general population [2].Current guidelines recommend that among patients with RHTN, spironolactone should be the first line therapy added to the three antihypertensive therapies that have failed to control the BP [1]. The PATHWAY-2 study (Spironolactone versus placebo, bisoprolol, and doxazosin to determine the optimal treatment for drug-resistant hypertension) was a multiway cross-over trial which demonstrated that spironolactone is more effective than placebo and an a-or b-blocker in improving BP control among patients with RHTN [3]. However, the PATHWAY-2 study excluded patients with estimated glomerular filtration rate (eGFR)< 45 mL/min/1.73 m2 as well as patients with hyperkalemia. These patients are often seen by nephrologists and may benefit from the addition of a mineralocorticoid receptor antagonist to their antihypertensive regimen. The European Society of Hypertension guideline discourages the use of spironolactone unless the eGFR is> 45 mL/min/1.73 m2 or serum potassium (K) is< 4.5 mEq/L. Thus patients with chronic kidney disease (CKD) are often denied spironolactone; furthermore, in a worldwide survey, the use of spironolactone among hypertensive patients with CKD was< 1%[4]. This is unfortunate as the prevalence of RHTN is several-fold higher in patients with advanced CKD [5]. Furthermore, cohort studies indicate that RHTN is associated with increased morbidity and mortality in this population [5, 6]. The use of drugs that block the mineralocorticoid receptor has been associated with nearly 2-fold increase in the risk of hyperkalemia [7]. The development of new drugs that bind K in the gut can potentially allow the use of spironolactone in higher risk patients. Recently, the Patiromer to Enable Spironolactone Use in the Treatment of Patients with RHTN and CKD (AMBER)
影响因子：
24
作者：
De Nicola, Luca;Gabbai, Francis B.;Minutolo, Roberto
通讯作者：
Minutolo, Roberto
影响因子：
3.3
作者：
Williams, Bryan;Mancia, Giuseppe;Lovic, Dragan
通讯作者：
Lovic, Dragan