Hypertension in Hemodialysis Patients

描述(申请人提供)：美国有超过316,000名终末期肾病患者，每年花费医疗保险约110亿美元。高血压是导致心血管疾病发病率和死亡率过高的重要因素，约占所有死亡人数的一半，然而，在美国绝大多数血液透析患者中，高血压的控制很差。目前还没有血液透析高血压的诊断和治疗指南。我们有初步证据表明，家庭血压监测可以准确诊断高血压，超滤和有监督的降压药物治疗可以加强高血压控制。具体目的1评价150例慢性血液透析患者常规血透单位血压监测和家庭血压监测诊断血液透析高血压的临床表现。透析间期动态血压将是黄金标准。在特定的目标2中，我们假设在一个普遍存在的血液透析队列中，达到“干重”可以迅速控制收缩压，可以通过超声心动图的容量超负荷迹象来预测，并且可以通过家庭血压监测准确地检测到。BP的这种改善也可以通过人口因素和成交量过剩的参数来预测。我们提出了一项为期8周的前瞻性随机超滤治疗试验，以评估超滤治疗控制收缩期血液透析高血压的有效性、安全性和耐受性。为了帮助临床医生做出决策，血容量过剩的特定标志物，如血浆BNP(脑钠素)、血浆肾素活性以及透析前后蛋白质浓度的变化将被评估为超滤治疗后血压改善的预测指标。在具体目标3中，我们假设，在血液透析高血压患者中，以血管紧张素转换酶抑制剂为基础的初始治疗策略比以β受体阻滞剂为基础的治疗在导致超声心动图左室肥厚(LVH)消退方面更有效。我们提出了一项平行分组、主动对照、随机对照试验，通过超声心动图评估透析后每周三次分别给予血管紧张素转换酶抑制剂和β-受体阻滞剂的初始单一治疗的安全性和有效性，以评估血压降低和左心室肥厚消退。总而言之，我们使用简单的策略来诊断血液透析患者的高血压，评估扩大的细胞外液容量的作用，并测试监督药物治疗对高血压控制的影响。我们还评估了床边测试的临床表现，以评估扩大的细胞外液体空间。对这些策略的评估将改善血液透析患者的血压控制，并从长远来看，提供心血管保护。

DESCRIPTION (provided by applicant): There are over 316,000 patients with end-stage renal disease in the USA that cost Medicare about $11 billion/year. Hypertension plays an important role in causing excess cardiovascular morbidity and mortality that accounts for approximately half of all deaths, yet hypertension is poorly controlled in the vast majority of the US hemodialysis patients. There are no guidelines for the diagnosis and treatment of hemodialysis hypertension. We have preliminary evidence that home BP monitoring can accurately diagnose hypertension and that ultrafiltration and supervised antihypertensive drug therapies can enhance hypertension control. In Specific Aim 1 we will evaluate the clinical performance of routine hemodialysis unit BP monitoring and home BP monitoring in the diagnosis of hemodialysis hypertension in 150 chronic hemodialysis patients. Interdialytic ambulatory BP will be the gold standard. In Specific Aim 2 we hypothesize that achieving "dry-weight" controls systolic hypertension rapidly in a prevalent hemodialysis cohort, can be predicted by echocardiographic signs of volume overload and can be accurately detected by home BP monitoring. This improvement in BP can be also predicted by demographic factors and parameters of volume excess. We propose an 8-week, prospective, randomized, trial of ultrafiltration therapy, to assess the efficacy, safety and tolerance of ultrafiltration therapy in controlling systolic hemodialysis hypertension. To assist clinicians in decision making, specific markers of volume excess such as plasma BNP (brain natriuretic peptide), plasma renin activity, and change in protein concentration from pre to post dialysis will be evaluated as predictors of improvement in BP with ultrafiltration therapy. In specific aim 3 we hypothesize that an initial strategy of treatment with an ACE inhibitor based therapy is more effective than beta-blocker based therapy in causing regression of echocardiographic left ventricular hypertrophy (LVH) in patients with hemodialysis hypertension. We propose a parallel group, active control, randomized controlled trial comparing the safety and efficacy of initial monctherapy with an ACE inhibitor versus a beta-blocker each administered three times weekly after dialysis to assess BP reduction and LVH regression by echocardiography. In summary, we use simple strategies to diagnose hypertension in hemodialysis patients, evaluate the role of expanded extracellular fluid volume and test supervised drug therapies to impact hypertension control. We also assess the clinical performance of bedside tests to assess an expanded extracellular fluid space. Evaluation of such strategies will improve BP control in hemodialysis patients and, in the long-term, provide cardiovascular protection.