本文選題：纈沙坦　切入點(diǎn)：慢性腎臟病急性加重　出處：《青島大學(xué)》2017年碩士論文　論文類型：學(xué)位論文

【摘要】：目的:探討血管緊張素II受體拮抗劑纈沙坦在治療慢性腎臟病急性加重期并惡性高血壓患者的臨床療效及安全性方法:在2012年12月至2016年12月青島大學(xué)醫(yī)學(xué)院附屬醫(yī)院腎內(nèi)科住院患者中,篩選出符合慢性腎臟病急性加重伴惡性高血壓診斷的,且隨訪時(shí)間達(dá)到4個(gè)月及以上的患者24例,對其進(jìn)行回顧性分析研究。選用纈沙坦并聯(lián)合其他降壓藥物治療控制血壓,纈沙坦初始劑量80-160mg/d,最大劑量320mg/d,血壓控制目標(biāo)設(shè)定為140/90mm Hg。達(dá)到治療量后,比較患者治療前及治療后2周、4周、8周、4月的血壓、血肌酐、24h尿蛋白、血紅蛋白、血鉀等指標(biāo)的變化情況,觀察纈沙坦在治療慢性腎臟病急性加重期并惡性高血壓患者的臨床療效及安全性。結(jié)果:所收集病例中,原發(fā)病為慢性腎小球腎炎繼發(fā)惡性高血壓10例,原發(fā)性惡性高血壓并腎損害12例,糖尿病性腎病繼發(fā)惡性高血壓2例;其中符合溶血尿毒綜合征診斷標(biāo)準(zhǔn)者5例。采集上述患者治療前及治療后2周末、4周末、8周末、4月末的血肌酐、尿素氮、尿蛋白、血鉀、血紅蛋白、血小板、血鈉、血氯、血二氧化碳結(jié)合力等指標(biāo)。治療后血紅蛋白、血小板等指標(biāo)均明顯改善,與治療前相比,P0.05,具有統(tǒng)計(jì)學(xué)意義。電解質(zhì)方面,其中4例患者在治療后2-4周出現(xiàn)血鉀輕度升高,經(jīng)限制高鉀飲食、間斷應(yīng)用利尿劑等治療措施4-8周后穩(wěn)定在正常水平;其中8例患者治療前存在代謝性酸中毒,給予糾酸藥物后均在治療后2周達(dá)到并穩(wěn)定在正常水平;血鈉、血氯水平與治療前比較均無顯著變化,P0.05,不具有統(tǒng)計(jì)學(xué)意義;觀察患者血壓,參考血壓控制目標(biāo)判斷血壓控制率。結(jié)果顯示第2周末時(shí)血壓控制率不足3.8%(1/26),血壓下降平均水平與治療前對比,P0.05,有統(tǒng)計(jì)學(xué)意義;第4周末時(shí)血壓控制率不足7.7%(2/26),血壓下降平均水平與治療前對比,P0.05,有統(tǒng)計(jì)學(xué)意義;第8周末時(shí)收縮壓控制率為54.2%(13/24),舒張壓控制率為45.8%(11/24),血壓下降平均水平與治療前比,P0.05,有統(tǒng)計(jì)學(xué)意義;第4月末時(shí)收縮壓控制率為50.0%(12/24),血壓下降平均水平與治療前比,P0.05,有統(tǒng)計(jì)學(xué)意義,與治療8周末比,P0.05,無統(tǒng)計(jì)學(xué)意義;第4月末時(shí)舒張壓控制率為41.7%(10/24),血壓下降平均水平與治療前比,P0.05,有統(tǒng)計(jì)學(xué)意義,與治療8周末比,P0.05,無統(tǒng)計(jì)學(xué)意義。觀察患者尿蛋白,參考尿蛋白下降水平判斷控制率,并通過個(gè)體化分析,對比纈沙坦為基礎(chǔ)的治療方案對不同原發(fā)病患者的療效。結(jié)果顯示治療第2周末及之后與治療前相比,整體尿蛋白水平有明顯下降,P0.05,有統(tǒng)計(jì)學(xué)差異,其中原發(fā)病為糖尿病性腎病組無明顯下降,P0.05,無統(tǒng)計(jì)學(xué)意義,原發(fā)病為惡性高血壓組及慢性腎小球腎炎組有明顯下降,P0.05,有統(tǒng)計(jì)學(xué)意義。觀察患者血肌酐、尿素氮,參考下降水平判斷療效。結(jié)果顯示治療第8周末及之后血肌酐、尿素氮下降水平與治療前相比,P0.05,有統(tǒng)計(jì)學(xué)差異;安全性分析:收集病例中患者在治療過程中,4例在治療后2-4周出現(xiàn)血鉀輕度升高,經(jīng)限制高鉀飲食、間斷應(yīng)用利尿劑等治療措施4-8周后穩(wěn)定在正常水平,2例患者出現(xiàn)一過性頭暈,1例患者自覺口腔金屬味,其余均未發(fā)生高血鉀、血肌酐病理性升高、頭暈、頭痛、惡心、咳嗽等不良反應(yīng)。結(jié)論:1.慢性腎臟病急性加重并惡性高血壓患者,ARB類藥物纈沙坦較為安全按,但若達(dá)到降壓目標(biāo),必須在纈沙坦基礎(chǔ)上聯(lián)合其他降壓藥物,但降壓效果與聯(lián)合藥物數(shù)量無顯著關(guān)系;2.纈沙坦可通過控制血壓、蛋白尿等,達(dá)到去除急性加重因素、改善腎功能的作用;3.纈沙坦通過血流動力學(xué)非血流動力學(xué)效應(yīng)發(fā)揮腎臟保護(hù)作用;4.ARB類藥物較ACEI類藥物具有更好地依從性;5.不同原發(fā)病人群應(yīng)用纈沙坦為基礎(chǔ)的治療方案,轉(zhuǎn)歸不同,其中原發(fā)性惡性高血壓、原發(fā)性腎小球腎炎優(yōu)于糖尿病性腎病。
[Abstract]:Objective: To investigate the effect of angiotensin II receptor antagonist valsartan on the clinical efficacy and safety of treatment of chronic kidney disease and acute exacerbation in patients with malignant hypertension: from December 2012 to December 2016 in the Affiliated Hospital of Medical College of Qiingdao University Department of Nephrology inpatients, selected in line with the diagnosis of malignant hypertension with acute exacerbation of chronic kidney disease, and the follow-up period to the patients in 4 months and more than 24 of the cases were analyzed retrospectively. The combined valsartan and other antihypertensive drugs to control blood pressure, initial dose of valsartan 80-160mg/d, maximum dose of 320mg/d, blood pressure control target set for 140/90mm Hg. reach the treatment amount, compared with 2 weeks before and after treatment for 4 weeks, 8 April week, blood pressure, serum creatinine, 24h urine protein, hemoglobin, changes of serum potassium and other indicators, observe the effect of valsartan in the treatment of chronic kidney disease with acute exacerbation And the clinical efficacy and safety in patients with malignant hypertension. Results: the collected cases, as the primary disease secondary to chronic glomerulonephritis in 10 cases of malignant hypertension, primary malignant hypertension and renal damage in 12 cases, 2 cases of diabetic nephropathy with malignant hypertension; 5 cases with hemolytic uremic syndrome diagnosis criteria. Acquisition the patients before treatment and 2 weeks after treatment, 4 weeks, 8 weeks, 4 at the end of the serum creatinine, urea nitrogen, urinary protein, serum potassium, hemoglobin, platelet, blood sodium, blood serum chloride, carbon dioxide combining power. The indexes of blood red protein after treatment, platelet indexes were significantly improved, compared to with P0.05 before treatment, with statistical significance. The electrolyte, including 4 patients in 2-4 weeks after treatment blood potassium increased slightly, by limiting high potassium diet, intermittent diuretic treatment after 4-8 weeks of stability in normal level; in the treatment of 8 cases The existence of metabolic acidosis, give correct acid drugs in 2 weeks after the treatment reached and stabilized at the normal level; the blood sodium, blood chlorine levels before treatment had no significant change, P0.05, was not statistically significant; observation of blood pressure, blood pressure control reference target judgment rate of blood pressure control. The results showed that second weekend when the blood pressure control rate of less than 3.8% (1/26), average blood pressure decreased compared with before treatment, P0.05, have statistical significance; at the end of the fourth week the blood pressure control rate of less than 7.7% (2/26), average blood pressure decreased compared with before treatment, P0.05, have statistical significance; at the end of the eighth week systolic blood pressure control rate was 54.2% (13/24) diastolic blood pressure, control rate was 45.8% (11/24), average blood pressure decreased compared with that before treatment, P0.05, have statistical significance; at the end of fourth when the systolic blood pressure control rate was 50% (12/24), average blood pressure decreased compared with that before treatment, P0.05 was statistically significant, P0.05 and 8 weeks of treatment, and no statistical significance; fourth end diastolic blood pressure control rate was 41.7% (10/24), average blood pressure decreased compared with that before treatment, with statistical significance, P0.05, P0.05 and 8 weeks of treatment, and no statistical significance. The observation of urinary protein, decreased urine protein levels to determine the control reference rate, and through individual analysis, treatment scheme comparison of valsartan based on the therapeutic effects of different primary disease patients. The results showed that after second week of treatment and compared with before treatment, the urine protein level decreased significantly, P0.05, have statistical differences, the primary disease of diabetic nephropathy group decreased significantly, P0.05. No statistically significant, malignant hypertension group and chronic glomerulonephritis group protopathy was decreased significantly, P0.05, have statistical significance. Observation of serum creatinine, urea nitrogen, decreased the level of reference to determine efficacy. Results showed that eighth weeks of treatment At the end of and after the blood creatinine and urea nitrogen levels decreased compared with before treatment, P0.05, there were significant differences; safety analysis: patients were collected in the course of treatment, 4 cases in 2-4 weeks after treatment, blood potassium increased slightly, by limiting high potassium diet, intermittent application of diuretics treatment measures after 4-8 weeks of stability at the normal level, 2 patients had dizziness, 1 cases of oral metallic taste, others were not have pathological hyperkalemia, serum creatinine increased, dizziness, headache, nausea, cough and other adverse reactions. Conclusion: 1. patients with acute exacerbation of chronic kidney disease in patients with malignant hypertension, ARB drug valsartan is safe according to the but, if to achieve goal, must be based on the combination of valsartan and other antihypertensive drugs, but the number of antihypertensive effect and no significant relationship between the 2. drug combination; valsartan can control the blood pressure, urine protein, to remove the acute aggravated factors, improve Renal function; 3. valsartan by hemodynamic non hemodynamic effects play a role in renal protection; 4.ARB drugs is ACEI drugs have better treatment compliance; 5., the incidence of different populations of valsartan based outcome, including primary malignant hypertension, primary glomerulonephritis than diabetic nephropathy.

【學(xué)位授予單位】：青島大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2017
【分類號】：R544.1;R692

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