nidНефрология и диализNephrology and Dialysis1680-44222618-9801Российское диализное обществоnid-211Research ArticleШКОЛА НЕФРОЛОГАEDUCATIONAL MATERIALSАртериальная гипертензия при ХБП: от начальных до продвинутых стадий. Диагностические и терапевтические стратегии. Часть 2. Заместительная почечная терапия (программный гемодиализ)Hypertension and chronic kidney disease: from initial to advanced stages. Diagnostic and therapeutic strategies. Part 2. Renal replacement therapy (maintenance hemodialysis)Зелтынь-АбрамовЕ. М.Zeltyn-AbramovE. M.ezeltyn@mail.ruЗемченковА. Ю.ZemchenkovA. Yu.noemail@neicon.ruГБУЗ «ГКБ №52 Департамента здравоохранения г. Москвы»; ФДПО ГБОУ ВПО РНИМУ им. Н. И. Пирогова МЗ РФРоссияMoscow City Hospital 52; Pirogov Russian National Research Medical University (RNRMU)Russian FederationФГБОУ ВО "Северо-Западный ГМУ им. И.И. Мечникова" Минздрава России; ФГБОУ ВО "Первый СПб ГМУ им. акад. И.П. Павлова" Минздрава РоссииРоссияNorth-Western State medical university named after I.I. Mechnikov; Pavlov First Saint Petersburg State medical universityRussian Federation202026072024222237251Copyright © Зелтынь-Абрамов Е.М., Земченков А.Ю., 20242024Зелтынь-Абрамов Е.М., Земченков А.Ю.Zeltyn-Abramov E.M., Zemchenkov A.Y.Данная работа распространяется под лицензией Creative Commons Attribution 4.0.This work is licensed under a Creative Commons Attribution 4.0 License.https://journal.nephro.ru/jour/article/view/211

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.

The article is devoted to actual problem in the diagnosis and treatment of arterial hypertension (AH) in patients on maintenance hemodialysis (MHD). The features of AH pathogenesis and progression inherent in the dialysis population: persistent volume overload, sodium retention, fluctuations in the volemic status, and progressive arterial stiffness were analyzed. One should take into account the clinical significance of other, often underestimated, causes of hypertension in patients on MHD. Among them, the obstructive sleep apnea syndrome, which should be considered as resulting from a volume overload rather than morbid obesity. Side effects of erythropoiesis-stimulating drugs, permanent sympathetic overactivity and persistent hyperactivity of the renin-angiotensin-aldosterone system are also of clinical importance. The contemporary approaches to the treatment of AH are based on results of numerous randomized clinical trials (RCTs) and a number of consensus documents and recommendations. Nonpharmacological methods are based on the improvement of dialysis and dietary strategies aimed on volemia control, preventing sodium retention, achieving and maintaining optimal dry weight. Change in the standard regimen of MHD increasing the number of dialysis sessions per week and its duration, and correction of the dialysate sodium depending on patient's plasma sodium seem also promising. Among dietary strategies, attention should be paid to patients' commitment to lifestyle modification, taking into account their psychological and socio-economic preferences. The pharmacological treatment of hypertension involves the use of modern classes of antihypertensive drugs, considering their pharmacokinetics on MHD, specific side effects and the risk of adverse cardiovascular events. The diagnostic modalities necessary for adequate control of AH are discussed: echocardiography - monitoring for realistic assessment of left ventricular hypertrophy, bio-impedance techniques for stepwise monitoring of dry weight and ultrasound of the lungs to objectify volume overload. Among the promising areas, the large-scale RCTs to determine the target parameters of hypertension and to objectify the effectiveness of existing treatment methods are needed. As an extension of therapeutic and surgical possibilities, it is proposed to pay attention to antihypertensive drugs of central action, renal denervation, renal artery embolization and bilateral nephrectomy.

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The authors declare that there are no conflicts of interest present.