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Dialyse aktuell 2012; 16(10): 576-582
DOI: 10.1055/s-0033-1333681
Dialyse
© Georg Thieme Verlag Stuttgart · New York

Therapierefraktärer Bluthochdruck bei Dialysepatienten – Welche Behandlungsoptionen können wir anbieten?

Therapy-resistant hypertension in hemodialysis patients –Which treatment options can we offer?
Wolfgang Weiß
1   CC10 – Schwerpunkt Nephrologie, Endokrinologie und Transplantationsmedizin, Campus Benjamin Franklin, Charité – Universitätsmedizin Berlin (Direktor: Prof. Dr. Walter Zidek)
,
Markus van der Giet
1   CC10 – Schwerpunkt Nephrologie, Endokrinologie und Transplantationsmedizin, Campus Benjamin Franklin, Charité – Universitätsmedizin Berlin (Direktor: Prof. Dr. Walter Zidek)
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Publication Date:
11 January 2013 (online)

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Unkontrollierter Bluthochdruck tritt bei Dialysepatienten mit einer Prävalenz von 80–100 % auf. Dies ist ein maßgeblicher Risikofaktor für ungünstige kardiovaskuläre Verläufe. Obwohl für Dialysepatienten bisher keine Definition des therapierefraktären Hypertonus vorliegt, zeigen sich trotz adäquater Einstellung des Trockengewichts viele Patienten weiterhin hypertensiv. Oftmals ist der Blutdruck auch durch eine Vielfachkombination von Antihypertensiva nicht beherrschbar. Neben dem grundsätzlichen Blutdruckmanagement bei Dialysepatienten sollen in dieser Übersichtsarbeit neben bewährten Behandlungsstrategien bei Therapierefraktärität auch neue interventionelle Verfahren zur Blutdrucksenkung diskutiert werden. Dabei präsentiert sich die renale Denervation derzeit als hoffnungsvollste Therapieergänzung und kann bereits mit positiven Ergebnissen bei Patienten mit chronischer Niereninsuffizienz und in einem Einzelfall mit dialysepflichtiger Niereninsuffizienz aufwarten. Dennoch müssen beim Einsatz neuer Verfahren das spezielle Risikoprofil dieser Patienten und insbesondere die Gefäßveränderungen chronisch niereninsuffizienter Patienten gesondert berücksichtigt werden. Weitere Untersuchungen bleiben daher abzuwarten, bevor der generelle Einsatz neuer interventioneller blutdrucksenkender Verfahren bei dieser Patientengruppe empfohlen werden kann.

Uncontrolled hypertension has a high prevalence of 80–100 % in end-stage renal disease (ESRD) patients. This is potentially a negative risk factor for cardiovascular events. Currently, there is no definition for therapy-resistant hypertension in ESRD patients. Many patients have hypertension despite optimal volume control. There are many procedures to optimize blood pressure in ESRD patients which are presented in this review. In the last years, new interventional procedures to control blood pressure have been developed. These procedures might be promising even for ESRD patients. There is already some experience with chronic kidney disease patients which are very promising. The question arises whether the procedures might also work in ESRD patients. The possible new procedures are discussed in the context of ESRD patients. Data are very limited.

Key words

therapy-resistant hypertension - hemodialysis - intervention - simplicity - baroreceptor stimulation
 

  • Literatur

  • 1 Calhoun DA, Jones D, Textor S et al. Resistant hypertension: diagnosis, evaluation, and treatment. A scientific statement from the American Heart Association Professional Education Committee of the Council for High Blood Pressure Research. Hypertension 2008; 51: 1403-1419
    CrossrefGoogle Scholar
  • 2 Hajjar I, Kotchen TA. Trends in prevalence, awareness, treatment, and control of hypertension in the United States, 1988–2000. JAMA 2003; 290: 199-206
    CrossrefGoogle Scholar
  • 3 Cushman WC, Ford CE, Cutler JA et al. Success and predictors of blood pressure control in diverse North American settings: the antihypertensive and lipid-lowering treatment to prevent heart attack trial (ALLHAT). J Clin Hypertens (Greenwich) 2002; 4: 393-404
    CrossrefGoogle Scholar
  • 4 Egan BM, Zhao Y, Axon RN et al. Uncontrolled and apparent treatment resistant hypertension in the United States, 1988 to 2008. Circulation 2011; 124: 1046-1058
    CrossrefGoogle Scholar
  • 5 Persell SD. Prevalence of resistant hypertension in the United States, 2003–2008. Hypertension 2011; 57: 1076-1080
    CrossrefGoogle Scholar
  • 6 Hanselin MR, Saseen JJ, Allen RR et al. Description of antihypertensive use in patients with resistant hypertension prescribed four or more agents. Hypertension 2011; 58: 1008-1013
    CrossrefGoogle Scholar
  • 7 Daugherty SL, Powers JD, Magid DJ et al. Incidence and prognosis of resistant hypertension in hypertensive patients. Circulation 2012; 125: 1635-1642
    CrossrefPubMedGoogle Scholar
  • 8 Pisoni R, Ahmed MI, Calhoun DA. Characterization and treatment of resistant hypertension. Curr Cardiol Rep 2009; 11: 407-413
    CrossrefGoogle Scholar
  • 9 Tomita J, Kimura G, Inoue T et al. Role of systolic blood pressure in determining prognosis of hemodialyzed patients. Am J Kidney Dis 1995; 25: 405-412
    CrossrefGoogle Scholar
  • 10 Mittal SK, Kowalski E, Trenkle J et al. Prevalence of hypertension in a hemodialysis population. Clin Nephrol 1999; 51: 77-82
    Google Scholar
  • 11 Agarwal R, Nissenson AR, Batlle D et al. Prevalence, treatment, and control of hypertension in chronic hemodialysis patients in the United States. Am J Med 2003; 115: 291-297
    CrossrefGoogle Scholar
  • 12 Amar J, Vernier I, Rossignol E et al. Nocturnal blood pressure and 24-hour pulse pressure are potent indicators of mortality in hemodialysis patients. Kidney Int 2000; 57: 2485-2491
    CrossrefGoogle Scholar
  • 13 Mazzuchi N, Carbonell E, Fernandez-Cean J. Importance of blood pressure control in hemodialysis patient survival. Kidney Int 2000; 58: 2147-2154
    CrossrefGoogle Scholar
  • 14 Takeda A, Toda T, Fujii T et al. Discordance of influence of hypertension on mortality and cardiovascular risk in hemodialysis patients. Am J Kidney Dis 2005; 45: 112-118
    CrossrefGoogle Scholar
  • 15 Foley RN, Parfrey PS, Harnett JD et al. Impact of hypertension on cardiomyopathy, morbidity and mortality in end-stage renal disease. Kidney Int 1996; 49: 1379-1385
    CrossrefGoogle Scholar
  • 16 Agarwal R, Sinha AD. Cardiovascular protection with antihypertensive drugs in dialysis patients: systematic review and meta-analysis. Hypertension 2009; 53: 860-866
    CrossrefGoogle Scholar
  • 17 Heerspink HJ, Ninomiya T, Zoungas S et al. Effect of lowering blood pressure on cardiovascular events and mortality in patients on dialysis: a systematic review and meta-analysis of randomised controlled trials. Lancet 2009; 373: 1009-1015
    CrossrefGoogle Scholar
  • 18 London GM, Pannier B, Guerin AP et al. Alterations of left ventricular hypertrophy in and survival of patients receiving hemodialysis: follow-up of an interventional study. J Am Soc Nephrol 2001; 12: 2759-2767
    Google Scholar
  • 19 Cannella G, Castellani A, Mioni G et al. Blood pressure control in end-stage renal disease in man: indirect evidence of a complex pathogenic mechanism besides renin or blood volume. Clin Sci Mol Med 1977; 52: 19-21
    Google Scholar
  • 20 Lins RL, Elseviers M, Rogiers P et al. Importance of volume factors in dialysis related hypertension. Clin Nephrol 1997; 48: 29-33
    Google Scholar
  • 21 Glatter KA, Graves SW, Hollenberg NK et al. Sustained volume expansion and [Na,K]ATPase inhibition in chronic renal failure. Am J Hypertens 1994; 7: 1016-1025
    Google Scholar
  • 22 Campese VM, Romoff MS, Levitan D et al. Mechanisms of autonomic nervous system dysfunction in uremia. Kidney Int 1981; 20: 246-253
    CrossrefGoogle Scholar
  • 23 Converse Jr RL, Jacobsen TN, Toto RD et al. Sympathetic overactivity in patients with chronic renal failure. N Engl J Med 1992; 327: 1912-1918
    CrossrefGoogle Scholar
  • 24 Odar-Cederlof I, Ericsson F, Theodorsson E, Kjellstrand CM. Is neuropeptide Y a contributor to volume-induced hypertension?. Am J Kidney Dis 1998; 31: 803-808
    CrossrefGoogle Scholar
  • 25 Eschbach JW, Kelly MR, Haley NR et al. Treatment of the anemia of progressive renal failure with recombinant human erythropoietin. N Engl J Med 1989; 321: 158-163
    CrossrefGoogle Scholar
  • 26 Raine AE, Roger SD. Effects of erythropoietin on blood pressure. Am J Kidney Dis 1991; 18 (Suppl. 01) 76-83
    Google Scholar
  • 27 Horl MP, Horl WH. Hemodialysis-associated hypertension: pathophysiology and therapy. Am J Kidney Dis 2002; 39: 227-244
    CrossrefGoogle Scholar
  • 28 Coomer RW, Schulman G, Breyer JA, Shyr Y. Ambulatory blood pressure monitoring in dialysis patients and estimation of mean interdialytic blood pressure. Am J Kidney Dis 1997; 29: 678-684
    CrossrefGoogle Scholar
  • 29 Massry SG, Iseki K, Campese VM. Serum calcium, parathyroid hormone, and blood pressure. Am J Nephrol 1986; 6 (Suppl. 01) 19-28
    CrossrefGoogle Scholar
  • 30 Goldsmith DJ, Covic AA, Venning MC, Ackrill P. Blood pressure reduction after parathyroidectomy for secondary hyperparathyroidism: further evidence implicating calcium homeostasis in blood pressure regulation. Am J Kidney Dis 1996; 27: 819-825
    CrossrefGoogle Scholar
  • 31 Zoccali C. ADMA: a critical cardio-renal link in heart failure?. Eur J Clin Invest 2003; 33: 361-362
    CrossrefGoogle Scholar
  • 32 Shaldon S. Can antihypertensive medications control BP in haemodialysis patients. Nephrol Dial Transplant 2000; 15: 736-736
    CrossrefGoogle Scholar
  • 33 Mailloux LU. The overlooked role of salt restriction in dialysis patients. Semin Dial 2000; 13: 150-151
    Google Scholar
  • 34 Law MR, Frost CD, Wald NJ. By how much does dietary salt reduction lower blood pressure? III--Analysis of data from trials of salt reduction. BMJ 1991; 302: 819-824
    CrossrefGoogle Scholar
  • 35 Charra B, Bergstrom J, Scribner BH. Blood pressure control in dialysis patients: importance of the lag phenomenon. Am J Kidney Dis 1998; 32: 720-724
    CrossrefGoogle Scholar
  • 36 Flanigan MJ, Khairullah QT, Lim VS. Dialysate sodium delivery can alter chronic blood pressure management. Am J Kidney Dis 1997; 29: 383-391
    CrossrefGoogle Scholar
  • 37 Reisin E. Nonpharmacologic approaches to hypertension. Weight, sodium, alcohol, exercise, and tobacco considerations. Med Clin North Am 1997; 81: 1289-1303
    CrossrefGoogle Scholar
  • 38 de Paula FM, Peixoto AJ, Pinto LV et al. Clinical consequences of an individualized dialysate sodium prescription in hemodialysis patients. Kidney Int 2004; 66: 1232-1238
    CrossrefGoogle Scholar
  • 39 Flanigan MJ. Role of sodium in hemodialysis. Kidney Int Suppl 2000; 76
    Google Scholar
  • 40 Perez-Garcia R, Lopez-Gomez JM, Jofre R et al. Haemodialysis dose, extracellular volume control and arterial hypertension. Nephrol Dial Transplant 2001; 16 (Suppl. 01) 98-101
    Google Scholar
  • 41 Chazot C, Charra B, Vo Van C et al. The Janus-faced aspect of 'dry weight'. Nephrol Dial Transplant 1999; 14: 121-124
    CrossrefGoogle Scholar
  • 42 Abdel-Kader K, Dohar S, Shah N et al. Resistant hypertension and obstructive sleep apnea in the setting of kidney disease. J Hypertens 2012; 30: 960-966
    CrossrefGoogle Scholar
  • 43 Hanly PJ, Pierratos A. Improvement of sleep apnea in patients with chronic renal failure who undergo nocturnal hemodialysis. N Engl J Med 2001; 344: 102-107
    CrossrefGoogle Scholar
  • 44 Tang SC, Lam B, Ku PP et al. Alleviation of sleep apnea in patients with chronic renal failure by nocturnal cycler-assisted peritoneal dialysis compared with conventional continuous ambulatory peritoneal dialysis. J Am Soc Nephrol 2006; 17: 2607-2616
    CrossrefGoogle Scholar
  • 45 Vaughan Jr ED, Carey RM, Ayers CR, Peach MJ. Hemodialysis-resistant hypertension: control with an orally active inhibitor of angiotensin-converting enzyme. J Clin Endocrinol Metab 1979; 48: 869-871
    CrossrefGoogle Scholar
  • 46 Mailloux LU, Levey AS. Hypertension in patients with chronic renal disease. Am J Kidney Dis 1998; 32 (Suppl. 03)
    Google Scholar
  • 47 Zazgornik J, Biesenbach G, Janko O et al. Bilateral nephrectomy: the best, but often overlooked, treatment for refractory hypertension in hemodialysis patients. Am J Hypertens 1998; 11: 1364-1370
    CrossrefGoogle Scholar
  • 48 Sanli O, Tefik T, Ortac M et al. Laparoscopic nephrectomy in patients undergoing hemodialysis treatment. JSLS 2010; 14: 534-540
    CrossrefGoogle Scholar
  • 49 Schlaich MP, Socratous F, Hennebry S et al. Sympathetic activation in chronic renal failure. J Am Soc Nephrol 2009; 20: 933-939
    CrossrefGoogle Scholar
  • 50 Zoccali C, Mallamaci F, Parlongo S et al. Plasma norepinephrine predicts survival and incident cardiovascular events in patients with end-stage renal disease. Circulation 2002; 105: 1354-1359
    CrossrefGoogle Scholar
  • 51 Di Daniele N, De Francesco M, Violo L et al. Renal sympathetic nerve ablation for the treatment of difficult-to-control or refractory hypertension in a haemodialysis patient. Nephrol Dial Transplant 2012; 27: 1689-1690
    CrossrefGoogle Scholar
  • 52 Esler MD, Krum H, Sobotka PA et al. Renal sympathetic denervation in patients with treatment-resistant hypertension (The Symplicity HTN-2 Trial): a randomised controlled trial. Lancet 2010; 376: 1903-1909
    CrossrefGoogle Scholar
  • 53 Ossareh S. Vascular calcification in chronic kidney disease: mechanisms and clinical implications. Iran J Kidney Dis 2011; 5: 285-299
    Google Scholar
  • 54 Schiffrin EL, Lipman ML, Mann JF. Chronic kidney disease: effects on the cardiovascular system. Circulation 2007; 116: 85-97
    CrossrefGoogle Scholar
  • 55 Ahmed H, Neuzil P, Skoda J et al. Renal sympathetic denervation using an irrigated radiofrequency ablation catheter for the management of drug-resistant hypertension. JACC Cardiovasc Interv 2012; 5: 758-765
    CrossrefGoogle Scholar
  • 56 Kottkamp H, Hindricks G, Horst E et al. Subendocardial and intramural temperature response during radiofrequency catheter ablation in chronic myocardial infarction and normal myocardium. Circulation 1997; 95: 2155-2161
    CrossrefGoogle Scholar
  • 57 Thiagalingam A, D'Avila A, Foley L et al. Importance of catheter contact force during irrigated radiofrequency ablation: evaluation in a porcine ex vivo model using a force-sensing catheter. J Cardiovasc Electrophysiol 2010; 21: 806-811
    Google Scholar
  • 58 Abdelwahab A, Sapp JL. NaviStar ThermoCool catheter for ventricular tachycardia. Expert Rev Med Devices 2007; 4: 307-314
    CrossrefGoogle Scholar
  • 59 Grassi G. Assessment of sympathetic cardiovascular drive in human hypertension: achievements and perspectives. Hypertension 2009; 54: 690-697
    CrossrefGoogle Scholar
  • 60 Lohmeier TE, Iliescu R, Dwyer TM et al. Sustained suppression of sympathetic activity and arterial pressure during chronic activation of the carotid baroreflex. Am J Physiol Heart Circ Physiol 2010; 299
    Google Scholar
  • 61 Augustyniak RA, Tuncel M, Zhang W et al. Sympathetic overactivity as a cause of hypertension in chronic renal failure. J Hypertens 2002; 20: 3-9
    CrossrefGoogle Scholar
  • 62 Klein IH, Ligtenberg G, Neumann J et al. Sympathetic nerve activity is inappropriately increased in chronic renal disease. J Am Soc Nephrol 2003; 14: 3239-3244
    CrossrefGoogle Scholar
  • 63 Heusser K, Tank J, Engeli S et al. Carotid baroreceptor stimulation, sympathetic activity, baroreflex function, and blood pressure in hypertensive patients. Hypertension 2010; 55: 619-626
    CrossrefGoogle Scholar
  • 64 Scheffers IJ, Kroon AA, Schmidli J et al. Novel baroreflex activation therapy in resistant hypertension: results of a European multi-center feasibility study. J Am Coll Cardiol 2010; 56: 1254-1258
    CrossrefGoogle Scholar
  • 65 Rubinger D, Backenroth R, Sapoznikov D. Restoration of baroreflex function in patients with end-stage renal disease after renal transplantation. Nephrol Dial Transplant 2009; 24: 1305-1313
    Google Scholar