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Том 22 №2 2020 год - Нефрология и диализ

Артериальная гипертензия при ХБП: от начальных до продвинутых стадий. Диагностические и терапевтические стратегии. Часть 2. Заместительная почечная терапия (программный гемодиализ)


Зелтынь-Абрамов Е.М. Земченков А.Ю.

DOI: 10.28996/2618-9801-2020-2-237-251

Аннотация: Статья посвящена актуальным вопросам диагностики и лечения артериальной гипертензии (АГ) у пациентов на программном гемодиализе (ПГД). Анализируются особенности патогенеза формирования и прогрессирования АГ, присущие диализной популяции: персистирующая перегрузка объемом, задержка натрия, колебания волемического статуса, прогрессирующая артериальная жесткость. Подчеркивается необходимость учета клинической значимости других причин АГ: перманентной гиперсимпатикотонии, сохраняющейся гиперактивности ренин-ангиотензин-альдостероновой системы. Важно учитывать побочные эффекты эритропоэз-стимулирующих препаратов, наличие у пациентов синдрома обструктивного апноэ сна. На основании данных многочисленных рандомизированных клинических исследований (РКИ), ряда согласительных документов и рекомендаций, представлены современные подходы к лечению АГ. Нефармакологические методы базируются на совершенствовании диализных и диетических стратегий, направленных на контроль волемии, предотвращение задержки натрия, достижения и удержания оптимального сухого веса. Перспективным представляется изменение стандартной процедуры ПГД в виде увеличения кратности или пролонгации диализных сессий, коррекция содержания натрия в диализном растворе в зависимости от его концентрации в плазме пациента. С точки зрения повышения эффективности диетических стратегий внимание уделяется приверженности пациентов к модификации образа жизни с учетом их психологических и социально-экономических предпочтений. Медикаментозное лечение АГ подразумевает использование современных классов гипотензивных препаратов с учетом влияния ПГД на их фармакокинетику. Обсуждаются необходимые для адекватного контроля АГ диагностические модальности - Эхо-КГ - мониторинг для реалистической оценки гипертрофии левого желудочка, биоимпедансные исследования для этапного контроля сухого веса и УЗИ легких для объективизации перегрузки объемом. Среди дальнейших направлений указывается необходимость продолжения проведения масштабных РКИ для определения целевых показателей АГ и объективизации эффективности существующих методов лечения. В качестве расширения терапевтических и хирургических возможностей предлагается уделить внимание гипотензивным препаратам центрального действия, денервации почек, эмболизации почечных артерий и билатеральной нефрэктомии.

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Ключевые слова: хроническая болезнь почек, гемодиализ, артериальная гипертензия, кардиоваскулярные риски, перегрузка объемом, задержка натрия, диализные стратегии, диетические ограничения, артериальная жесткость, chronic kidney disease, hemodialysis, hypertension, cardiovascular risks, volume overload, sodium retention, dialysis strategies, salt restriction, arterial stiffness

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