Diagnosis and treatment specification for hypertension after solid organ transplantation in China (2019 edition)
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摘要: 为了进一步规范中国实体器官移植术后高血压的诊断和治疗,中华医学会器官移植学分会组织器官移植专家和心血管病专家,在《实体器官移植受者的高血压诊疗指南(2015版)》的基础上,结合我国器官移植后高血压的临床现状,并参考《中国高血压防治指南》,从流行病学和发病率、定义和诊断标准、危险因素和病理生理、移植后高血压的治疗等方面,制定中国实体器官移植术后高血压诊疗规范(2019版)。
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表 1 血压水平的分类和定义
Table 1. Classification and definition of blood pressure levels(mmHg)
类别 收缩压 舒张压 正常血压 < 120 < 80 正常高值 120~139 80~89 高血压 ≥140 ≥90 1级高血压(轻度) 140~159 90~99 2级高血压(中度) 160~179 100~109 3级高血压(重度) ≥180 ≥110 单纯收缩压高 ≥140 < 90 表 2 常用免疫抑制剂导致移植术后高血压的相关机制
Table 2. Related mechanism of hypertension after transplantation caused by the immunosuppressant commonly used
类别 药物 机制 CNI
他克莫司、环孢素
提高血管张力:降低一氧化氮(nitric oxide, NO)、升高内皮素水平
增加交感神经兴奋性
激活血管紧张素-醛固酮系统:血压升高、水钠潴留
激活远端小管的钠-氯协同转运受体:钠重吸收增加, 容量过多
肾毒性:通过缩血管效应导致AKI
慢性缺血、肾小球硬化、致间质纤维化和萎缩mTORi
西罗莫司
代谢异常:血脂、血糖异常
致蛋白尿
增加额外的CVE风险糖皮质激素
甲泼尼龙
增加交感神经兴奋性
增加血管张力
增加盐皮质激素活性表 3 简化危险分层项目内容
Table 3. Project contents of simplified risk stratification
项目 内容 高血压分级
1级:收缩压140~159 mmHg或舒张压90~99 mmHg
2级:收缩压160~179 mmHg或舒张压100~109 mmHg
3级:收缩压≥180 mmHg或舒张压≥110 mmHg危险因素 年龄、吸烟、血脂异常、早发心血管家族史、肥胖或腹型肥胖 靶器官损害 左心室肥厚、颈动脉内膜增厚或斑块、血清肌酐轻度增高 临床疾病 脑血管病、心脏病、肾脏病、周围血管病、视网膜病变、糖尿病 表 4 根据心血管总体危险量化估计预后危险度分层
Table 4. Prognostic risk stratification based on quantitative estimation of total cardiovascular risk
其他危险因素、靶器官损害和疾病情况 高血压1级 高血压2级 高血压3级 无其他危险因素 低危 中危 高危 1~2个危险因素 中危 中危 高危 ≥3个危险因素、靶器官损害、并存的临床疾病 高危 高危 高危 表 5 改变生活方式治疗的内容、目标和效果
Table 5. The content, goal and effect of lifestyle change therapy
内容 目标 预期降压效果 减少钠盐摄入 每日钠盐摄入量逐步降至 < 6 g/d, 肾功能正常者可适当补充钾盐 2~8 mmHg 体育运动 强度:中等量, 每周3~5次, 每次30 min 4~9 mmHg 合理膳食 营养均衡 8~14 mmHg 控制体质量 BMI < 24 kg/m2, 腰围 < 90 cm (男性)、 < 85 cm (女性) 5~20 mmHg/减重10 kg 戒烟 彻底戒烟、避免被动吸烟 限制饮酒 每日白酒 < 50 mL, 或葡萄酒 < 100 mL或啤酒 < 300 mL, 建议戒酒 2~4 mmHg BMI为体质量指数 -
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