Hikmet TEKÇE, Gülali AKTAŞ, Seyhun KÜRŞAT

Son dönem böbrek yetmezliğinde hipertansiyon ve patogenezi; sodyum ve volüm kontrolünün önemi

Hipertansiyon, son dönem böbrek yetmezliği SDBY hastalarında oldukça yaygın görülen bir klinik problemdir. Buna karşın bu hastaların etkin kan basıncı kontrolünden çoğu zaman uzak olmasının önemli bir sebebi, bu hasta grubunda hipertansiyon fizyopatolojisinin karmaşık, multifaktoriyel ve az anlaşılmış olmasından kaynaklanmaktadır. Hemodiyaliz hastalarındaki hipertansiyonun patogenezinde majör risk faktörlerinden ikisi, artmış ekstrasellüler volüm ve sodyum alımıdır. Buradan yola çıkarak terapödik hedefin anahatları da bu etyopatogenez çerçevesinde belirlenmelidir. Bulgular SDBY hastalarında sodyum yüklenmesinin, volüm yüklenmesi ve hipertansiyonla paralel seyrettiğini düşündürmektedir. Bu durum sodyumun, hipertansiyon için kilit bir rol oynadığını ve tedavinin yönetiminde esas uğraşı alanının antihipertansif ilaç desteği değil, tuz kısıtlaması ve gereğinde ek ultrafiltrasyon desteğinin olması yönündeki mücadelenin merkezi rolünü düşündürmektedir.

Anahtar Kelimeler:

Son dönem böbrek yetmezliği, hipervolemi, sodyum

The pathogenesis of hypertension in end stage renal disease; the importance of the sodium and volume control

Hypertensions is a common clinical problem among patients with end stage renal failure. Because physiopathology of hypertension in these patients is multifactoriel, complicated and less understood, effective blood pressure control usually can not be achieved in this population. Major two risk factors in the pathogenesis of hypertension in patients receiving hemodialysis treatment are extracellular volume and dietary sodium intake. Therapeutic targets should be determined according to etiopathogenesis. There is increasing number of evidence indicating sodium intake in patients with end stage renal failure is related to volume overload and hypertension. Because sodium plays a key role in hypertension development among these population, salt restriction and additional ultrafiltration, if necessary, should be the mainstay of the antihypertensive treatment instead of antihypertensive drugs.

Keywords:

End stage renal disease, hypervolemia, sodium,

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Jimmy W, Tariq S, Allen R.N. Role of sodium and volume in the pathogenesis of hypertension in hemodialysis. Semi- nars in Dialysis 2000; 17: 260–264.
Salem M. Hypertension in the hemodialysis population? High time for answers. Am J Kidney Dis 1999; 33: 592–594.
Rocco MV, Yan G, Heyka RJ, Benz R, Cheung AKl, HEMO Study Group. Risk factors for hypertension in chronic he- modialysis patients: baseline data from the HEMO study. Am J Nephrol 2001; 21: 280–288.
Horl M, Horl W. Hemodialysis-associated hypertension: pathophysiology and therapy. Am J Kidney Dis 2002; 39: 227–244.
Rahman M, Dixit A, Donley V, Gupta S, Hanslik T, Lacson E, Ogundipe A, Weigel K, Smith MC. Factors associated with inadequate blood pressure control in hypertensive hemo- dialysis patients. Am J Kidney Dis 1999; 33: 498–506.
Foley RN, Parfrey PS, Hartnett JD, Kent GM, Murray DC, Barre PE. Impact of hypertension on cardiomyopathy, mor- bidity and mortality in end-stage renal disease. Kidney Int 1996; 49: 1379–1385.
Grekas D, Bacharaki D, Goutzaridis N, Kasimatis E, Tourkan- tonis A. Hypertension in chronic hemodialysis patients: cur- rent view on pathophysiology and treatment. Clin Nephrol 2000; 3: 164–168.
Leypoldt JK, Cheung AK, Delmez JA Gassman JJ, Levin NW, Lewis JA, Lewis JL, Rocco MV. Relationship between volume status and blood pressure during chronic hemodialysis. Kidney Int 2002; 61: 266–275.
Lins LE, Hedenborg G, Jacobson SH, Samuelson K, Tedner B, Zetterholm UB, Ljungqvist O. Blood pressure reduction during hemodialysis correlated to intradialytic changes in plasma volume. Clin Nephrol 1992; 37: 308–313.
Tozawa M, Iseki K, Iseki C, Morita O, Yoshi S, Fukiyama K. Seasonal blood pressure and body weight variation in pa- tients on chronic hemodialysis. Am J Nephrol 1999; 19: 660–667.
Blumberg A, Nelp WD, Hegstrom RM, Scribner BH. Extracel- luler volume in patients with chronic renal disease treated for hypertension by sodium restriction. Lancet 1967; 2: 69– 73.
Amico M, Locatelli F. Hypertension in dialysis: pathophysi- ology and treatment. J Nephrol 2002; 15: 438–445.
Scribner BH. A personalized history of hemodialysis. Am J Kidney Dis 1990; 16: 511–519.
Chazot C, Bergstrom J, Scribner BH: Blood pressure control in dialysis patients: the importance of the lag phenomenon. Am J Kidney Dis 1998; 32: 720–724.
Ruffman K, Mandelbaum A, Bommer J, Schmidli M, Ritz E. Doppler echocardiographic findings in dialysis patients. Nephrol Dial Transplant 5: 426–431,1990
Charra B. Control of blood pressure in long slow hemodialy- sis. Blood Purif 1994; 28: 252–258.
Charra B, Calemard E, Ruffet M, Chazot C, Terrat JC, Vanel T, Laurent G. Survival as an index of adequacy of dialysis. Kidney Int 1992; 41: 1286–1291.
Katzarski KS, Charra B, Luik AJ, Nisell J, Divino Filho JC, Leypoldt JK, Leunissen KM, Laurent G, Bergström J. Fluid state and blood pressure control in patients treated with long and short hemodialysis. Nephrol Dial Transplant 1999; 14: 369–375.
Velasquez MT, von Albertini B, Lew SQ, Mishkin GJ, Bosch JP. Equal levels of blood pressure control in ESRD patients receiving high-efficiency hemodialysis and conventional hemodialysis. Am J Kidney Dis 1998; 31: 618–623.
Guyton AC, Hall JE: Textbook of Medical Physiology. Phila- delphia, Saunders, 2000.
Hamlyn JM, Hamilton BP, Manunta P: Endogenous oubain, sodium balance and blood pressure: a review and a hy- pothesis. J Hypertens 1996; 14: 151–167.
Intersalt Cooperative Research Group. Intersalt: an interna- tional study of electrolyte excretion and blood pressure. Results for 24 h urinary sodium and potassium excretion. BMJ 1988; 297: 319–328.
Kempner W. Treatment of hypertensive vascular disease with rice diet. Am J Med 1945; 8: 545–577.
Midgley JP, Matthew AG, Greenwood CM, Logan AG. Effect of reduced dietary sodium on blood pressure: a meta- analysis of randomized controlled trials. JAMA 1996; 275: 1590–1597.
Sacks FM, Svetkey LP, Vollmer WM, Appel LJ, Bray GA, Harsha D, Obarzanek E, Conlin PR, Miller ER, III, Simons- Morton DG, Karanja N, Lin PH. Effects on blood pressure of reduced dietary sodium and the Dietary Approaches to Stop Hypertension (DASH) diet. DASH-Sodium Collaborative Research Group. N Engl J Med 2001; 344: 3–10.
Pimenta E, Gaddam KK, Oparil S, Aban I, Husain S, Dell’Italia LJ, Calhoun DA. Effects of dietary sodium reduction on blood pressure in subjects with resistant hypertension: re- sults from a randomized trial. Hypertension 2009; 54: 475– 481.
Charra B, Chazot C, Jean G, Laurent G. Long, slow dialysis. Miner Electrolyte Metab 1999; 24: 391–396.
Ozkahya M, Toz H, Ozerkan F, Duman S, Ok E, Basci A, Mees EJ. Impact of volume control on left ventricular hypertro- phy in dialysis patients. J Nephrol 2002; 12: 655–660.
Krautzig S, Janssen U, Koch KM, Granolleras C, Shaldon S. Dietary salt restriction and reduction of dialysate sodium to control hypertension in maintenance haemodialysis pa- tients. Nephrol Dial Transplant 1998; 13: 552–553.
Ozkahya M, Toz H, Unsal A, Ozerkan F, Asci G, Gurgun C, Akcicek F, Mees EJ. Treatment of hypertension in dialysis patients by ultrafiltration: role of cardiac dilatation and time factor. Am J Kidney Dis 1999; 34: 218–221.
31. Kayikcioglu M, Tumuklu M, Ozkahya M, Ozdogan O, Asci G, Duman S, Toz H, Can LH, Basci A, Ok E. The benefit of salt restriction in the treatment of end-stage renal disease by haemodialysis. Nephrol Dial Transplant 2009; 24: 956– 96.