Hypertension in Hemodialysis Patients

描述（由申请人提供）：该项目的长期目标是了解家庭血压监测在高血压管理中的作用，容量过载在高血压引起的作用以及血液透析患者高血压的药物治疗。我们假设容量控制可以改善血压，抗高血压治疗可以缓解长期血液透析患者的左心室肥厚。具体目标：#1。在一项150例患者的随机试验中，我们发现容量控制可以在4周内改善血液透析患者的高血压，并持续到8周。为了提高对高血压的诊断，预测对超滤的反应，探讨血液透析患者高血压控制的机制，我们对收集到的数据进行了4项额外的分析。# 2。我们建议完成一项正在进行的随机对照试验，比较β受体阻滞剂和基于ace抑制剂的降压治疗对左室肥厚消退的影响。方法：应用程序的目标1有以下4个分析：1。为了支持使用家庭血压来诊断和管理高血压，我们将测试超滤组与对照组相比家庭血压改善的关系以及与动态血压改善的一致性。我们预计，家庭血压和动态血压之间的协议将超过透析单位血压和动态血压之间的协议。2. 为了揭示容量过载的标记，我们将评估一组预测超滤后血压下降的标记。我们期望超滤组患者在4项指标定义的容量过载时动态血压有所改善。3. 为了评估动态血压作为容量过载标志的价值，我们将分析超滤组与对照组相比动态血压模式变化的关系。我们预计，超滤组将有动态血压模式的根本变化，由趋势余弦模型评估。4. 为了确定动脉僵硬对高血压的影响，我们将分析超滤对脉搏波速度的改善。我们期望超滤能改善动脉僵硬度和动态血压。该申请的目的2是一项平行组、主动对照、单中心、随机开放标签试验，比较赖诺普利与每周一次以β受体阻滞剂阿替洛尔为基础的治疗在超声心动图左心室肥厚消退的主要结局变量上的安全性和有效性。血压控制将通过家庭血压记录来实现。意义：心血管疾病是血液透析患者死亡的主要原因，高血压是心血管疾病的主要诱因。在此应用中发展的血液透析患者高血压的诊断、管理和治疗策略，当应用于更大的透析患者群体时，可能会改善血压控制和更好的心血管预后。新颖性：容量指数作为过量容量的标志，以及趋势余弦模型用于分析血液透析患者的血流动力学模式是我们早期资助的新发现。将这些新模型应用于随机对照试验将把数学表达式转化为活生生的临床工具。公共卫生相关性：心血管死亡是血液透析患者死亡的主要原因。该项目的长期目标是了解家庭血压监测在高血压管理中的作用，容量过载在高血压引起的作用以及血液透析患者高血压的药物治疗。我们假设容量控制可以改善血压，抗高血压治疗可以缓解长期血液透析患者的左心室肥厚。

DESCRIPTION (provided by applicant): The long-term goal of this project is to understand the utility of home BP monitoring in managing hypertension, role of volume overload in causing hypertension and drug therapy in the treatment of hypertension in hemodialysis patients. We hypothesize that that volume control can improve BP and antihypertensive therapy can regress left ventricular hypertrophy in long-term hemodialysis patients. Specific aims: #1. In a randomized trial of 150 patients we have shown that volume control improves hypertension in hemodialysis patients within 4 weeks that persists at 8 weeks. To improve the diagnosis of hypertension, predict the response to ultrafiltration and explore the mechanisms of hypertension control in hemodialysis patients we propose 4 additional analyses on the data collected. #2. We propose to complete an ongoing randomized controlled trial of beta- blocker versus ACE-inhibitor based antihypertensive therapy in effecting regression of left ventricular hypertrophy. Methods: Aim 1 of the application has 4 analyses which are as follows: 1. To support the use of home BP to diagnose and manage hypertension we will test the relationship of home BP improvement in the ultrafiltration group compared to controls and the agreement with improvement in ambulatory BP. We expect that the agreement between home BP and ambulatory BP will exceed the agreement between dialysis unit BP and ambulatory BP. 2. To uncover the markers of volume overload, we will evaluate a panel of markers that predict BP fall with ultrafiltration. We expect an improvement in ambulatory BP in the ultrafiltration group when patients are volume overloaded as defined by a panel of 4 markers. 3. To evaluate the value of ambulatory BP as a marker of volume overload, we will analyze the relationship of change in patterns of ambulatory BP in the ultrafiltration group compared to controls. We expect that the ultrafiltration group will have fundamental changes in patterns of ambulatory BP as assessed by the trended cosinor model. 4. To determine the contribution of arterial stiffness in causing hypertension, we will analyze the improvement in pulse wave velocity in response to ultrafiltration. We expect that ultrafiltration will lead to improvement in arterial stiffness and ambulatory BP. Aim 2 of the application is a parallel group, active control, single-center, randomized open-label trial comparing the safety and efficacy of lisinopril vs. beta- blocker atenolol-based therapy each administered three times weekly after dialysis on the primary outcome variable of regression of echocardiographic left ventricular hypertrophy. BP control will be achieved by home BP recordings. Significance: Cardiovascular disease is the major cause of death in hemodialysis patients and hypertension a major contributor of cardiovascular disease. The strategies of diagnosis, management and treatment of hypertension in hemodialysis patients developed in this application when applied to a larger population of dialysis patients may result in improved BP control and better cardiovascular outcomes. Novelty: The volume index developed as a marker of excess volume and the trended cosinor model developed to analyze hemodynamic patterns in hemodialysis patients are novel discoveries from our earlier grant. Application of these novel models to randomized controlled trials would transform a mathematical expression to a live clinical tool. PUBLIC HEALTH RELEVANCE: Cardiovascular mortality is the major cause of death in patients on hemodialysis. The long-term goal of this project is to understand the utility of home BP monitoring in managing hypertension, role of volume overload in causing hypertension and drug therapy in the treatment of hypertension in hemodialysis patients. We hypothesize that that volume control can improve BP and antihypertensive therapy can regress left ventricular hypertrophy in long-term hemodialysis patients.