Objektif tansyon nan CKD 2021: Debak Gid ki pa janm fini an

REZIME

An 2021, yo te pibliye de direktiv klinik aktyalize, baykonsèy sou san presyon(BP) objektif pou moun ki gen maladi ren kwonik (CKD).Maladi ren: Amelyore rezilta mondyal yo(KDIGO) mete ajou Gid pratik klinik 2012 li pou Jesyon BP nan CKD.Diferan tansyon sistolik(SBP) ak sib tansyon dyastolik (DBP) pou CKD (<130/80 and <140/90 mmHg, respectively, for people with urinary albumin: creatinine ratio >30 mg / g oswa san albuminuria patolojik) yo te ranplase pa yon nimewo sèl: yon sib SBP nan<120 mmHg is suggested when tolerated. This represents a major decrease in the SBP target and the abandonment of DBP targets. The European Society of Cardiology (ESC) also published a 2021 Clinical Guideline on Cardiovascular Disease Prevention in Clinical Practice that updates a prior 2016 guideline on prevention and the 2018 ESC/European Society of Hypertension Clinical Practice Guidelines for the Management of Arterial Hypertension. The 2021 ESC guideline was endorsed by 12 European scientific societies. The recommended office BP targets for people with CKD are <140–130 mmHg SBP (lower SBP is acceptable if tolerated) and <80 mmHg DBP. The question is: What should the practicing physician do now: treat hypertension in people with CKD to an SBP target of <120 mmHg or to a target of <140–130 mmHg? Major guideline bodies are aware of the activities of other major players. There is an urgent need for guideline bodies to establish communication channels, search for consensus on major issues that impact the health of hundreds of millions of people worldwide, and end individualism in guidelines generation. 

Mo kle: sib tansyon,maladi ren kwonik, Sosyete Ewopeyen an kadyoloji, direktiv, tansyon wo

KONBYEN TAN LI PRAN POU CISTANCHE TRAVAY?

Anviwon 850 milyon moun atravè lemond genyenmaladi ren kwonik (CKD) and >80% nan yo gen tansyon wo [1]. Yon gwo pwopòsyon nan moun ki gen tansyon wo, ki gen prévalence atravè lemond te estime an 2000 nan 972 milyon dola, ka gen CKD koncomitan. Mòtalite ki soti nan CKD ap ogmante rapidman epi li prevwa li pral vin senkyèm kòz mondyal lanmò nan 2040 ak dezyèm kòz lanmò anvan fen syèk la nan kèk peyi ki gen esperans lavi long [2, 3]. Pran aksyon pou anpeche prévisions sa yo konkretize se yon pi gwo priyorite swen sante [4]. Lanmò kadyovaskilè se youn nan pi gwo kontribitè nan mòtalite nan CKD [5]. Kidonk, fikse objektif pou kontwòl tansyon (BP) nan CKD pral afekte risk lanmò twò bonè pou dè santèn de milyon moun atravè lemond e li gen potansyèl pou afekte gwo kòz lanmò nan pwochen deseni yo. Sepandan, gwo kò direktiv yo pa dakò sou objektif BP pou CKD [6, 7]. Kidonk, yon sitiyasyon ki an 2019 te rele chaotic nan paj CKJ ap pèsiste nan nouvo dekad la [8]. Pandan ke ta ka gen jistifikasyon pou direktiv ki te pwodwi nan diferan pwen nan tan egzamine prèv diferan sijere/rekòmande diferan sib BP, gen ti jistifikasyon pou de gid ki pibliye sou 5 mwa lè l sèvi avèk menm prèv la bay rekòmandasyon trè divergent.

Figi 1:Diferan objektif terapetik nan CKD pasyan yojan yo sijere oswa rekòmande pa ansyen (2012–18) oswa pi nouvo (2021 oswa pa fèk mete ajou) direktiv yo. (A) Gid ki pi ansyen yo: Gid pratik klinik KDIGO 2012 pou Jesyon Tansyon nan Maladi Ren kwonik, Gid 2017 ACC/AHA ak Gid 2018 ESC/ESH. (B) Gid 2021 KDIGO ak ESC ak Gid 2017 ACC/AHA yo poko mete ajou e konsa yo konsidere yo rete aktyèl. Tanpri sonje ke sib ki ka geri yo diferan ant gid, menm ant de direktiv ki te pibliye an 2021. Koulè ble kolòn yo reprezante BP sib la. Valè nimerik endividyèl yo an wouj reprezante valè ki pi wo nan twa direktiv yo pou menm konsèp la (sistolik oswa dyastolik BP), an zoranj, se valè entèmedyè, ak an vèt, valè ki pi ba yo nan twa direktiv yo pou menm konsèp la. Panel (A) adapte de [8]. Yo pwopoze objektif KDIGO pou CKD ki pa dyaliz, ki pa transplantasyon. Pou moun ki resevwa transplantasyon ren yo, sib KDIGO 2021 BP yo te modifye sèlman modèsman<130 mmHg SBP and <80 mmHg DBP. KDIGO 2021 provides no recommendations for patients on dialysis. ESC guidelines do not provide specific advice for kidney transplant recipients or patients on dialysis.

An 2021, de gwo direktiv ki te mete ajou anvan (ki date depi 2012 ak 2018, respektivman) rekòmandasyon pou objektif BP pou moun ki gen CKD: Maladi ren: Amelyore rezilta mondyal (KDIGO) Gid pratik klinik 2021 pou jesyon tansyon nan maladi ren kwonik. [6] ak Sosyete Ewopeyen an nan kadyoloji (ESC) 2021 Gid klinik sou prevansyon maladi kadyovaskilè nan pratik klinik [7]. Tou de nouvo gid bay yon mesaj senplifye ki pral favorize absòpsyon ak aplikasyon. Malerezman, sib tansyon sistolik (SBP) sijere/rekòmande yo te koupe jiska 20 mmHg. Sa a kreye konfizyon epi yo pral anpeche aplikasyon an. Gen yon bezwen ijan pou rive nan yon konsansis sou pwoblèm debaz tankou BP vize pou dè santèn de milyon moun ki gen CKD.

SOTI KDIGO 2012 POU KDIGO 2021 GID PRATIK KLINIK POU JESYON TASYON NAN CKD Gid KDIGO 2012 la te gen yon seri objektif BP relativman konplèks ki baze sou prezans oswa absans dyabèt oswa albuminuri patolojik [sa vle di albumin urin: rapò kreyatinin (UACR). > 30 mg/g] pou granmoun ki gen CKD ki pa sou dyaliz (Fig. 1A) [9]: • Rekòmandasyon: ki pa dyabetik, UACR<30 mg/g; office SBP target ≤140 mmHg, DBP ≤90 mmHg (1B). • Suggestion: non-diabetic, UACR 30–300 mg/g; office SBP targets ≤130 mmHg, DBP ≤80 mmHg (2D for UACR 30–300 and 2C for UACR > 300 mg/g in non-diabetics, 2D for diabetics).

Sa vle di, pou KDIGO 2012, yon BP nan 140/90 mmHg te adekwat pou pasyan ki pa dyabetik, CKD normoalbuminuric. Pa te gen okenn rekòmandasyon pou pasyan sou dyaliz, pandan ke pasyan transplantasyon te gen menm sib la ak pasyan ki gen albuminuria patolojik [9]. Gid KDIGO 2021 la gen yon mesaj ki pi senp: 'Nou sijere ke adilt ki gen tansyon wo ak CKD dwe trete ak yon SBP sib nan.<120 mmHg, when tolerated, using standardized office BP measurement (2B)' (Fig. 1B) [6]. Additionally, it guides how to measure office BP (Table 1). The suggestion is based on the Systolic Blood Pressure Intervention Trial (SPRINT) [10]. SPRINT randomly assigned participants to an SBP target of <120 mmHg or <140 mmHg. Patients with an estimated glomerular filtration rate <20 mL/min/1.73 m2, 24-h urine protein excretion >1 g, sou dyaliz oswa resevwa transplantasyon ren yo te eskli. Nan sougwoup pasyan ki gen CKD, BP reyalize nan 1 ane te 123.3 ± 0.4/66.9 ± 0.3 mmHg kont 136.9 ± 0.4/73.8 ± {{ 16}}.3 mmHg [11]. Nan pasyan ki gen CKD, apre yon swivi medyàn nan 3.3 ane, rapò risk pou rezilta prensipal kadyovaskilè konpoze an te 0.81 [95% entèval konfyans (CI) 0.63-1. {{30}}5] ak pou tout kòz lanmò li te 0.72 (95% CI 0.53-0.99), men pasyan ki gen yon sib SBP nan<120 mmHg lost GFR at a 47% faster rate (–0.47 versus –0.32 mL/min/1.73 m2/year; P < 0.03). SPRINT measured BP in a standardized manner (Table 1). However, in SPRINT, there were four different groups of patients about the presence of the doctor or study personnel during rest or the actual BP readings (attended versus unattended BP) [12], a factor that can directly influence the levels of measured BP [13]. These four groups displayed no homogeneity in the primary study outcome, a fact that makes the interpretation of the SPRINT results quite difficult.

Tablo 1. Kondisyon estanda pou mezi BP biwo

Tablo 1. Kontinye

Tablo 2. Sosyete syantifik ki andose sib ESC 2021 SBP nan<140–130 mmHg for people with CKD

Pou moun ki resevwa transplantasyon ren, sib BP yo te sèlman modèsman modifye<130 mmHg SBP and <80 mmHg DBP. Again, KDIGO 2021 provides no recommendations for patients on dialysis. From 2018 ESC/European Society of Hypertension (ESH) Clinical Practice Guidelines for the Management of Arterial Hypertension to 2021 ESC Clinical Guidelines on Cardiovascular Disease Prevention in clinical practice (endorsed by 12 European scientific societies, including the ESH) (Table 2). The 2018 ESC/ESH guidelines contained a complex set of suggestions to determine whether to start therapy for hypertension, based on age [13]. Thus patients with CKD >80 ane ki gen laj pa ta kòmanse terapi famasi pou tansyon wo jiskaske SBP yo te pi gran pase oswa egal a 160 mmHg oswa DBP pi gran pase oswa egal a 90 mmHg. Kontrèman, nan pasyan ki pi piti yo, papòt la pou kòmanse terapi te 140/90 mmHg. Sepandan, yon fwa yo te kòmanse terapi, sib la te menm bagay la tou pou pasyan CKD granmoun tout laj: 130-139 mmHg SBP ak 70-79 mmHg DBP (Fig. 1A). Objektif CKD a te pi wo pase sa pou pi piti (18-65 ane) moun nan popilasyon jeneral la oswa pou dyabetik, nan ki moun sib la te 120-129 mmHg SBP, ak yon remak ke li pa ta dwe.<120 mmHg. This discrepancy in the target BP for patients with CKD versus those with diabetes or individuals from the general population was not supported by any kind of observational or clinical trial evidence. ESC 2021 decreases differential SBP thresholds at which to initiate therapy based on age but still recommends a higher SBP target (130–139 mmHg) in adults with CKD of any age (Fig. 1B) than in younger people in the general population or in diabetics (120–130 mmHg if <70 years of age and 130–139 mmHg for those ≥70 years of age) [7]. A more subtle change to the 2018 document deemed a lower SBP acceptable in CKD if tolerated. Additionally, the DBP target is universally <80 mmHg for all treated patients, independent of any associated comorbidity. The proposed BP assessment method is similar to that proposed by KDIGO 2021 (Table 1), ruling out that methodological differences explain the different BP targets. ESC 2021 does not provide the rationale for target BP values in people with CKD and does not mention the SPRINT subanalysis of participants with CKD or the 2021 KDIGO guideline on BP and CKD, although it does cite other KDIGO guidelines on lipids and diabetes, one of which was accessed in June 2021 [7]. However, it does explain changes from the prior 2016 ESC prevention and 2018 ESC/ESH hypertension guidelines in the cut-off for identifying who is 'older' (from 65 to 70 years for reasons of consistency with other parts of the current guidelines), in BP targets for the elderly (based on the SPRINT subanalysis of people ≥75 years of age and others) and the rationale for BP targets for people with lower extremity artery disease [13–15].