Publication: Hipertensión arterial refractaria en pacientes con enfermedad renal crónica: pautas de optimización del tratamiento diurético
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2018-11-07
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Universidad Complutense de Madrid
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Abstract
La HTA resistente se asocia de forma muy estrecha con la ERC. Existen diversos mecanismos implicados en esta asociación y resistencia, pero el principal es la sobrecarga de volumen intravascular. Por ello, la optimización del tratamiento diurético en estos pacientes debería ser clave para mejorar el control de la PA.
Planteamos que diferentes estrategias basadas en la optimización del tratamiento diurético son capaces de mejorar el control de la PA y enlentecer la progresión de la ERC.
Para confirmar esta hipótesis realizamos varios estudios cuyos objetivos principales fueron:
- Analizar la prevalencia de la HTA resistente en una población con ERC y analizar las características de estos pacientes
- Evaluar el estado de hidratación de los pacientes con ERC e HTA resistente mediante la realización de bioimpedancia.
- Evaluar el efecto sobre el control de la PA en pacientes con HTA resistente de dos estrategias terapéuticas basadas en la optimización del tratamiento diurético: intensificación del tratamiento diurético vs antagonistas de la aldosterona.
- Analizar el impacto del control de presión arterial de las dos estrategias terapéuticas: intensificación del tratamiento diurético vs antagonistas de la aldosterona, en la progresión de la enfermedad renal
Las principales conclusiones de nuestros estudios fueron:
- La prevalencia de HTA resistente aumenta con la edad, el grado de ERC y albuminuria.
- El aumento del VEC es frecuente en los pacientes con ERC e HTA resistente, incluso en estadios iniciales de la ERC.
- La BIS es potencialmente un método útil para identificar a los pacientes con ERC y sobrecarga de volumen y puede ayudar como guía para ajustar el tratamiento diurético.
- El ajuste del tratamiento diurético guiado por BIS en pacientes con HTA resistente reduce de forma eficaz las cifras de PA
- La espironolactona es más eficaz que la furosemida para el control de la presión arterial y albuminuria en pacientes con HTA resistente.
- El tratamiento con espironolactona a largo plazo en pacientes con HTA resistente reduce más la PA y la proteinuria que la furosemida y estos efectos se asocian con una progresión más lenta de la enfermedad renal.
Resistant hypertension is associated with chronic kidney disease (CKD). There are several mechanisms involved in this association, but the main mechanism is intravascular volume overload. Therefore, the optimization of diuretic treatment in these patients should be the key to improve BP control. We argue that in patients with CKD strategies based on the optimization of diuretic treatment may help to better control BP and slow CKD progression. In order to confirm this hypothesis, we made several studies whose main objectives were: - To analyze the prevalence of resistant hypertension in a population with CKD and analyze the characteristics of these patients - To Evaluate the hydration status of patients with CKD and resistant hypertension by performing bioimpedance. - To evaluate the effect on the control of BP in patients with resistant hypertension of two therapeutic strategies based on the optimization of diuretic treatment: intensification diuretic vs aldosterone antagonists treatment. - To analyze the impact of blood pressure control of the two therapeutic strategies: intensification diuretic vs aldosterone antagonists treatment, in the renal disease progression in a group of patients with resistant hypertension The main findings were: - Resistant hypertension prevalence increases with age, degree of CKD and albuminuria. - Extracellular volume overload is common in patients with CKD and resistant hypertension, even in the early stages of CKD. - Bioimpedance is potentially a useful method for identifying patients with CKD and volume overload and can help us to guide the adjustment of diuretic treatment. - Adjustment of diuretic therapy with bioimpedance in patients with resistant hypertension effectively reduces BP - Spironolactone is more effective than furosemide for the control of blood pressure and albuminuria in patients with resistant hypertension. - Long treatment with spironolactone in patients with resistant hypertension significantly reduces BP and proteinuria compared with furosemide and these effects are associated with a slower progression of renal disease.
Resistant hypertension is associated with chronic kidney disease (CKD). There are several mechanisms involved in this association, but the main mechanism is intravascular volume overload. Therefore, the optimization of diuretic treatment in these patients should be the key to improve BP control. We argue that in patients with CKD strategies based on the optimization of diuretic treatment may help to better control BP and slow CKD progression. In order to confirm this hypothesis, we made several studies whose main objectives were: - To analyze the prevalence of resistant hypertension in a population with CKD and analyze the characteristics of these patients - To Evaluate the hydration status of patients with CKD and resistant hypertension by performing bioimpedance. - To evaluate the effect on the control of BP in patients with resistant hypertension of two therapeutic strategies based on the optimization of diuretic treatment: intensification diuretic vs aldosterone antagonists treatment. - To analyze the impact of blood pressure control of the two therapeutic strategies: intensification diuretic vs aldosterone antagonists treatment, in the renal disease progression in a group of patients with resistant hypertension The main findings were: - Resistant hypertension prevalence increases with age, degree of CKD and albuminuria. - Extracellular volume overload is common in patients with CKD and resistant hypertension, even in the early stages of CKD. - Bioimpedance is potentially a useful method for identifying patients with CKD and volume overload and can help us to guide the adjustment of diuretic treatment. - Adjustment of diuretic therapy with bioimpedance in patients with resistant hypertension effectively reduces BP - Spironolactone is more effective than furosemide for the control of blood pressure and albuminuria in patients with resistant hypertension. - Long treatment with spironolactone in patients with resistant hypertension significantly reduces BP and proteinuria compared with furosemide and these effects are associated with a slower progression of renal disease.
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Tesis de la Universidad Complutense de Madrid, Facultad de Medicina, Departamento de Medicina, leída el 29-05-2017