血液透析患者における家庭血圧測定の意義

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  • Clinical usefulness of home blood pressure measurement in patients on chronic hemodialysis
  • ケツエキ トウセキ カンジャ ニ オケル カテイ ケツアツ ソクテイ ノ イギ

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Blood pressure (BP) measured at home (HBP) has been recognized as a useful predictor of organ damage and viewed as an important therapeutic target in patients with hypertension. This study aimed to elucidate whether this tenet holds true for patients on long-term hemodialysis (HD). Enrolled in the study were 106 patients with chronic renal failure receiving standardized HD. They were all directed to record self-measured HBP in the morning and at bedtime to evaluate the adequacy of BP control. In addition, cardiovascular complications were estimated by measuring the plasma concentration of BNP and ANP whose clinical implications were analyzed in conjunction with BP. The results were as follows; 1) HBP in the morning shows the predominance of morning hypertension (81.1% when determined in systolic HBP and 45.3% in diastolic HBP). The overall status of BP control assessed as a classification based upon the relationship between HBP in the morning and office/clinic BP (OBP) shows that patients with well-controlled systolic HBP in the morning comprised 9.4%, those with poorly-controlled, 65.1%, masked hypertension, 16% and white-coat hypertension, 9.4%. Additionally, HBP at bedtime also shows the predominance of hypertension (68.9% when determined by systolic HBP and 34.9% by diastolic HBP). The status of BP control shows that patients with well-controlled systolic HBP at bedtime comprised 12.3%, those with poorly-controlled, 55.7%, masked hypertension, 13.2% and white-coat hypertension 18.9%. 2) Systolic HBP in the morning (150±23mmHg) was significantly higher than that at bedtime (145±20mmHg, p=0.0297 by Scheffe's method), and was comparable to systolic OBP (150±20mmHg). In contrast, diastolic HBP in the morning, diastolic HBP at bedtime and diastolic OBP were all comparable. 3) There was a significant correlation between logarithmically converted BNP (In (BNP) expressed as BNP) and systolic HBP in the morning (r=0.249, p=0, 0098), and systolic HBP at bedtime (r=0.266, p=0.0057). However, there was no apparent relationship between BNP and systolic OBP. 4) There was a significant correlation between logarithmically converted ANP (In (ANP) expressed as ANP) and HBP (both systolic (r=0.381, p=0.0112) and diastolic (r=0.322, p=0.0346)) in the morning. There was also a significant correlation between In (ANP) and either systolic (r=0.521, p=0.0003)) or diastolic OBP (r=0.453, p=0.002) obtained at the end of HD. However, there was no such relationship when evaluated using either HBP at bedtime or OBP. This study indicates that despite ongoing conventional antihypertensive therapy and vigorous efforts to appropriately correct fluid status with standardized HD, the majority of patients on HD have hypertension, suggesting that patients with chronic renal failure are still at higher risk for cardiovascular diseases. Moreover, left ventricular dysfunction accessed by an increase in BNP and excessive volume status accessed by an increase in ANP were predicted by HBP, but not by OBP. To ameliorate hypertension, more appropriate pharmacological interventions and intensive fluid volume management in association with HBP must be further considered for these patients.

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