摘要目的 探讨不同肾功能水平难治性高血压(RH)患者动态血压相关指数改变的临床意义.方法 回顾性分析2010年10月至2013年10月北京安贞医院高血压科住院患者401例的临床资料(其中RH患者263例,非RH患者138例),代入中国人修正“肾脏病膳食改良试验”(MDRD)公式评估肾功能(以GFR ＜60 ml·min-1·1.73 m-2为明显肾损害标准),进行24h动态血压监测得到各项血压参数;采用受试者工作特征曲线(ROC)判断各项动态血压指数改变在预测RH患者明显肾脏功能损害中的作用;采用多因素Logistic回归分析RH患者明显肾脏功能损害相关影响因素.结果 以GFR＜60 ml·min-1·1.73 m-2为切点构建RH患者动态血压参数ROC工作特征曲线提示动态动脉硬化指数(AASI)、24 h平均脉压(24 hPP)、收缩压夜间血压下降率(SBP夜间血压下降率)和24 h平均收缩压(24 hSBP)改变对RH肾功能损害有预测诊断作用,其各自截点值和ROC下面积分别为AASI≥0.485,0.804,P=0.000;24 hPP≥47.5 mmHg,0.644,P=0.006; SBP夜间血压下降率≤-1.75％,0.602,P=0.019;24 hSBP≥130.5 mmHg,0.623,P=0.008.多因素Logistic回归分析结果显示RH合并慢性肾脏病(CKD)相关危险因素有AASI(OR 1 268.5,P=0.000)、LDL水平(OR 0.7,P=0.01)和SBP夜间血压下降率(OR 1.3,P=0.01)是GFR ＜60 ml·min-1·1.73 m-2的独立危险因素.结论 动态血压相关参数改变对RH患者肾脏功能明显损害具有重要意义,其中AASI、24 hPP、SBP夜间血压下降率和24 hSBP的改变是预测RH患者明显肾功能损害的重要指标.

abstractsObjective To explore the predictive values of ambulatory blood pressure-related parameters for moderate renal impairment in resistant hypertension (RH).Methods The clinical data were retrospectively analyzed for 401 hospitalized patients with hypertension at our hospital from October 2010 to October 2013.They were divided into RH (n =263) and non-RH (n =138).The modified estimating equation of glomerular filtration rate (GFR) for Chinese patients was used to assess renal functions.The standardization of moderate renal impairment was when GFR below 60 ml · min-1 · 1.73 m-2.The ambulatory blood pressure-related parameters were obtained by 24 h ambulatory blood pressure monitoring.The important prediction of these parameters for moderate renal impairment was accessed by receiver operating characteristic (ROC) curve.And the related risk factors for renal function impairment were tested by multiple stepwise Logistic regression analysis.Results Ambulatory arterial stiffness index (AASI),24 h mean pulse pressure (24 hPP),sleeptime relative systolic blood pressure (SBP) decline and 24 h systolic blood pressure (24 hSBP) had important predictive values for moderate renal impairment in RH.GFR was significantly lower in those with AASI ≥0.485,24 hPP ≥47.5 mmHg,sleeptime relative SBP decline ≤-1.75％ and 24 hSBP ≥ 130.5 mmHg (P ＜ 0.05).Area under curve of ROC curve of AASI,24 hPP,sleeptime relative SBP decline and 24 hSBP were 0.804,0.644,0.602 and 0.623 respectively.Multiple Logistic regression analysis showed that AASI (OR 1 268.5,P =0.000),low density lipoprotein (OR 0.7,P =0.01) and sleeptime relative SBP decline (OR 1.3,P =0.01) were independent risk factors for GFR ＜ 60 ml · min-1 · 1.73 m-2 in RH.Conclusion AASI,24 hPP,sleeptime relative SBP decline and 24 hSBP are the most significant ambulatory blood pressure-related parameters in predicting renal impairment in resistant hypertension.