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去肾交感神经术治疗难治性高血压

李清霖 张宇清

李清霖, 张宇清. 去肾交感神经术治疗难治性高血压[J]. 协和医学杂志, 2020, 11(1): 6-11. doi: 10.3969/j.issn.1674-9081.20190251
引用本文: 李清霖, 张宇清. 去肾交感神经术治疗难治性高血压[J]. 协和医学杂志, 2020, 11(1): 6-11. doi: 10.3969/j.issn.1674-9081.20190251
Qing-lin LI, Yu-qing ZHANG. Renal Sympathetic Denervation in the Treatment of Resistant Hypertension[J]. Medical Journal of Peking Union Medical College Hospital, 2020, 11(1): 6-11. doi: 10.3969/j.issn.1674-9081.20190251
Citation: Qing-lin LI, Yu-qing ZHANG. Renal Sympathetic Denervation in the Treatment of Resistant Hypertension[J]. Medical Journal of Peking Union Medical College Hospital, 2020, 11(1): 6-11. doi: 10.3969/j.issn.1674-9081.20190251

去肾交感神经术治疗难治性高血压

doi: 10.3969/j.issn.1674-9081.20190251
详细信息
    通讯作者:

    张宇清 电话:010-88398778, E-mail:yqzhang99@yahoo.com

  • 中图分类号: R544.1

Renal Sympathetic Denervation in the Treatment of Resistant Hypertension

More Information
  • 摘要: 难治性高血压(resistant hypertension, RH)是指在改善生活方式基础上应用可耐受的足够剂量且合理的3种降压药物(包括一种噻嗪类利尿剂)治疗至少4周后, 诊室和诊室外(包括家庭血压或动态血压监测)血压值仍在目标水平之上, 或至少需要4种降压药物才能使血压达标, 目前尚缺乏有效的治疗方案。去肾交感神经术(renal sympathetic denervation, RDN)作为RH的一种治疗手段, 在病理生理机制上已被基础实验证实。早期Ⅰ代RDN的临床试验结果并不统一, Ⅱ代RDN改进了消融技术并在最近的高血压临床试验应用中得到了阳性结论, 同时RDN用于治疗其他疾病的临床试验也产生了阳性结果。但由于目前尚无对肾交感神经活动的具体评估方法, 无法准确筛选出适宜行RDN的人群, 故其临床应用仍存在争议。
    利益冲突  无
  • 表  1  Ⅰ代RDN与Ⅱ代RDN主要临床试验及其结果

    临床试验 血压入选标准 样本量 基线血压(mmHg) 随访时间(月) SBP[RDN组/对照组或RDN组-对照组 P
    诊室血压 24 h动态血压
    Ⅰ代RDN
      SYMPLICITY RH* 45 SBP≥160 未应用 12 -27/-17 0.020
      HTN-1[32]
      SYMPLICITY RH*且除 100 SBP≥160或SBP≥ 应用,但未在所有入 6 -33/-11 <0.001
      HTN-2[33-35] 外T1DM 150(合并T2DM 选样本中测定
      SYMPLICITY RH* 535 SBP≥160 SBP≥135 6 △SBP:-2.39 0.260
      HTN-3[36] (-6.89~2.12)
    △24 h SBP:-1.96 0.980
    (-4.97~1.06)
      SYMPLICITY RH* 41 SBP≥160 SBP>135 6 △SBP:-8.64 0.169
      HTN-Japan[39] (-21.12~3.84)
    △24 h SBP:-6.15 0.087
    (-13.23~0.94)
      SYMPLICITY RH* 67 未报道 白天SBP 135~149或 6 △24 h SBP:-3.5 0.150
      Flex[40] 白天DBP 90~94 (-8.5~1.5)
      DENER-HTN[41] RH* 101 SBP≥140或DBP≥90 白天平均SBP≥135 6 △24 h SBP:-5.9# 0.033
    或白天平均DBP≥85 (-11.3~-0.5)
      SYMPATHY[42] RH* 124 平均BP:(169±25)/ 白天平均SBP:160± 6 △SBP:-8.2# 0.069
    (96±16) 17且白天平均DBP: (-17.1~0.7)
    93±15 △24 h SBP:1.0 0.805
    (-7.1~9.1)
      RDN伴OSA[43] RH*合并 60 SBP≥140 白天平均SBP≥135 3 △SBP:-17# 0.002
    中重度OSA (-27~-6)
    △24 h SBP:-9 0.008
    (-17~-3)
    Ⅱ代RDN
      SPYRAL HTN-ON RH*合并 80 150≤SBP<180且DBP 140≤平均SBP<170 6 △SBP -6.8 0.021
      MED[22] ≥90 (-12.5~-1.1)
    △24 h SBP -7.4 0.005
    (-12.5~-2.3)
      SPYRAL HTN-OFF 轻中度高 80 150≤SBP<180且 140≤平均SBP<170 3 △SBP:-7.7 0.016
      MED[23] 血压§ DBP≥90 (-14.0 ~-1.5)
    △24 h SBP -5.0 0.041
    (-9.9~-0.2)
    *除外eGFR<45 ml/(min·1.73 m2)、继发性高血压、肾脏解剖结构及一般情况不适合行RDN术的患者,且所有患者在入组前均予≥3种降压药物规范治疗,基线血压为在规律口服降压药物(血管紧张素转换酶抑制剂/血管紧张素受体拮抗剂、β受体拮抗剂、钙通道阻滞剂、利尿剂)治疗下测定;#DENER-HTN研究比较了RDN联合标准的阶梯降压治疗和单纯阶梯降压治疗的血压变化,两组血压下降幅度平均差为-5.9 mmHg;§20~80岁轻中度高血压,所有入选者在入组前均已停用降压药物,基线血压为停用降压药物3~4周时测定,所有入选者均经肾血管造影等排除了不适合行RDN术的情况;RDN:去肾交感神经术;RH:难治性高血压;T1DM:1型糖尿病;T2DM:2型糖尿病;OSA:阻塞性睡眠呼吸暂停;SBP:收缩压;DBP:舒张压;△SBP:收缩压变化;△24 h SBP:24 h动态收缩压变化; eGFR:估算的肾小球滤过率
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  • 收稿日期:  2019-11-13
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