目的 探讨高血压伴动脉粥样硬化性肾动脉狭窄(ARAS)患者的肾功能保护治疗策略。方法 纳入2019-12至2022-06行肾动脉造影发现单侧或双侧肾动脉狭窄程度≥30%的高血压伴ARAS患者77例。根据治疗方式分为最佳药物治疗(OMT)组和“OMT+肾动脉血运重建(RAR)”(OMTR)组,并进行随访。按照不同的肾动脉狭窄程度将单侧ARAS患者分为四组:轻度狭窄组(狭窄30% ~ 49%)、中度狭窄组(狭窄50% ~ 69%)、重度狭窄组(狭窄70%~89%)、极重度狭窄组(狭窄≥90%)。比较并随访各组患者狭窄侧与健侧的分侧肾脏功能(SRF)。结果 OMT组(n=46)治疗3个月时降压药物种类有所增加(P<0.05),收缩压及舒张压较治疗前有升高趋势,通过增加或者优化药物后其收缩压逐渐下降(随访12个月时与3个月相比,P<0.05),血清肌酐(SCr)水平在随访期间内未见明显升高;31例行RAR后,术后6个月时降压药物种类及SCr水平有所增加或增高(P<0.05),优化药物后在随访12个月时SCr水平下降(与随访6个月相比,P<0.05),随访期间内血压水平未见明显变化;OMTR组与OMT组相比,两组基线血压无明显差异,但OMTR组患者的基线SCr水平更高(P<0.05),在随访终点(12个月)时两组患者的收缩压、舒张压、降压药物种类及SCr水平均无明显差异;在单侧ARAS患者中(n=42),患侧肾脏的肾小球滤过率(GFR)与健侧肾脏相比,仅极重度狭窄组有显著降低[(27.94±16.51)ml/min vs. (46.47±16.30)ml/min;P<0.05],术后SRF检测有2例极重度狭窄的患者出现患侧GFR的显著改善。结论 对于高血压伴ARAS患者,无论是否进行RAR治疗,密切随访并不断优化调整OMT方案十分重要,稳定地控制患者血压有助于防止高血压肾损害的发生;肾动脉极重度狭窄(狭窄≥90%)的ARAS患者发生缺血性肾病的风险极大,RAR治疗可能使此类患者获益。
Abstract
Objective To explore the therapeutic strategy of renal function protection in hypertensive patients with atherosclerotic renal artery stenosis (ARAS). Methods A total of 77 hypertensive patients with unilateral or bilateral renal artery stenosis (≥30%) by renal arteriography from December 2019 to June 2022 were enrolled in this study. The patients were treated with optimal medical therapy (OMT) and “OMT + renal artery revascularization” (OMTR) and were followed up. Patients with unilateral ARAS were divided into four groups according to different degree of renal artery stenosis: mild stenosis group (30%－49%), moderate stenosis group (50%－69%), severe stenosis group (70%－89%) and extremely severe stenosis group (≥90%). The split renal function (SRF) of the stenotic side and the contralateral side were compared and followed up. Results In OMT group (n=46), the types of antihypertensive drugs increased after 3 months of treatment (P<0.05), with an upward trend of the systolic and diastolic blood pressure. After drug adjustment and optimization, the systolic blood pressure decreased significantly at 12 months of follow-up compared with 3 months (P<0.05),and the serum creatinine (SCr) level did not increase significantly during the follow-up period. For 31 patients receiving renal artery revascularization (RAR), the types of antihypertensive drugs and SCr levels increased at 6 months after operation (P<0.05), then the SCr levels decreased at 12 months of follow-up compared with 6 months after drug optimization (P<0.05), and blood pressure levels did not change significantly during follow-up. Compared with the OMT group, there was no significant difference in baseline blood pressure between the two groups, but the baseline SCr level of patients in the OMTR group was higher (P<0.05), and there was no significant difference in blood pressure, types of antihypertensive drugs and SCr level between the two groups at the end point of follow-up (12 months). For patients with unilateral ARAS (n=42), the glomerular filtration rate (GFR) in the affected side of kidney was significantly lower compared with the contralateral healthy kidney in the extremely severe stenosis group [(27.94±16.51)ml/min vs.(46.47±16.30)ml/min;P<0.05]. Postoperative SRF test also showed that two patients with extremely severe renal artery stenosis had an improvement in GFR on the affected side of kidney. Conclusions For hypertensive patients with ARAS, it is of great importance to closely follow up and continuously optimize the OMT strategy regardless of RAR treatment is carried out. Stable control of blood pressure is helpful to prevent the occurrence of hypertensive kidney damage. ARAS patients with extremely severe renal artery stenosis(≥90%) are at high risk for ischemic kidney disease and may benefit from RAR therapy.
关键词
动脉粥样硬化性肾动脉狭窄 /
高血压 /
最佳药物治疗 /
肾动脉血运重建
Key words
atherosclerotic renal artery stenosis /
hypertension /
optimal medical therapy /
renal artery revascularization
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