目的

分析慢性肾脏病(CKD)患者不同病理类型与血压水平和昼夜节律异常的相关性,及后者与肾小动脉病变程度的关系。

方法

收集济南军区总医院、解放军117 医院、北京大学第三医院2008 年至2013 年行肾活检且行24 h 动态血压监测的CKD 患者1746 例,根据2013 年欧洲高血压实践指南对患者血压进行分析判断。 24 h 平均血压≥130/80 mmHg 为高血压;夜间血压下降幅度= [(白天血压-夜间血压)/白天血压] ×100%;夜间血压下降＞20%为深勺型节律,10% ～20%为勺型节律,＜10%为非勺型节律,＜0%为反勺型节律;将深勺型和勺型定义为正常血压节律,非勺型和反勺型定义为异常血压节律。 病理诊断与分型参照1995 年WHO 肾小球疾病组织学分型修订方案和国内2001 年肾活检病理诊断标准指导意见。 肾脏小动脉损伤评分参照IgA 肾病牛津分型的评分标准进行评分。

结果

(1)1746 例患者年龄(47.4 ±24.9)岁,男性929 例(占53.2%);24 h 平均血压≥130/80 mmHg 560 例(32.1%)、白天平均血压≥135/85 mmHg 474 例(27.1%)、夜间平均血压≥120/70 mmHg 762 例(43.6%);深勺型血压38 例(2.2%)、勺型血压647 例(37.1%)、非勺型血压908 例(52.0%)、反勺型血压155 例(8.9%)。 (2)不同病理类型CKD 患者高血压发生率为,糖尿病肾病75.5%(74 例)、局灶节段肾小球硬化症41.8%(62 例)、IgA 肾病39.2%(246 例)、狼疮性肾炎25.2%(41 例)、膜性肾病22. 3% (37 例)、肾小球轻微病变与系膜增生性肾小球肾炎18. 4%(100 例),各组之间差异有统计学意义(χ² =163.309, P ＜0.001)。 不同病理类型CKD 患者血压昼夜节律异常发生率为,糖尿病肾病81.6%(80 例)、局灶节段肾小球硬化症64.2%(95 例)、IgA 肾病66.7%(419 例)、狼疮肾炎58.9%(96 例)、膜性肾病51.8%(86 例)、肾小球轻微病变与系膜增生性肾小球肾炎52.9%(287 例),各组之间差异有统计学意义(χ² = 48.087, P ＜0.001)。 (3)根据IgA肾病牛津评分对肾组织小动脉进行评分,0 ～1 分(未见小动脉明显病变)789 例,其中高血压发生率10.6%(84 例)、血压节律异常发生率57.9%(457 例);2 ～4 分(肾小动脉轻度病变)632 例,其中高血压发生率35.4%(224 例)、血压节律异常发生率56.0%(354 例);5 ～7 分(肾小动脉重度病变)326 例,其中高血压发生率77.3%(252 例)、血压节律异常发生率74.2%(242 例),分别比较差异有统计学意义(χ² = 475.8, χ² =219.647; P ＜0.001)。 秩相关性分析显示,血压水平越高以及夜间血压水平下降越少,肾脏小动脉损伤越重。

结论

CKD 患者高血压和血压节律异常发生率高,尤其是糖尿病肾病和IgA 肾病患者;CKD 患者肾脏小动脉病变程度与高血压及血压节律异常相关。

Objective

To investigate the relationship between pathological type and blood pressure level or its circadian rhythm, as well as the relationship between the latter and the lesion degree of renal arterioles in patients with chronic kidney disease.

Methods

Data of 1746 cases with chronic kidney disease were collected form our hospitals who underwent renal biopsies and 24-hour ambulatory blood pressure monitoring from 2008-2013, and were analyzed according to the 2013 European Society of Hypertension Practice Guidelines. 24 h average blood pressure ≥130/80 mmHg was referred to as hypertension.Nocturnal blood pressure decline rate =[(daytime blood pressure-nocturnal blood pressure)/daytime blood pressure] ×100%. Nocturnal blood pressure decline ＞20% was referred to as extreme dippers rhythm,10%-20% as dippers rhythm, ＜10% as nondipper rhythm, and ＜0% as risers rhythm. Both the extreme dippers rhythm and the dippers rhythm were defined as normal circadian rhythm, while the nondipper and risers rhythms defined as the abnormal blood pressure rhythm. The pathological diagnosis and typing were in reference to the 1995 WHO Glomerular Diseases Histological Type Amendments and the domestic 2001 Renal Biopsy Pathological Diagnosis Standard Guidance. Renal arteriole injury score standard was in reference to the IgA nephropathy Oxford typing score system.

Results

(1) Age range of the 1746 cases was 47.4 ±24.9 years, including 929 male cases (53.2%). The 24 h average blood pressure was ≥130/80 mmHg in 560 cases (32.1%), the daytime average blood pressure ≥135/85 mmHg in 474 cases (27.1%), and the nocturnal average blood pressure ≥120/70 mmHg in 762 cases (43. 6%). Extreme dippers blood pressure was in 38 cases (2. 2%), dippers blood pressure in 647 cases (37. 1%), nondipper blood pressure in 908 cases (52%), and risers blood pressure in 155 cases (8.9%). (2) The incidence of hypertension in patients with different pathological types of CKD was 75. 5% (74 cases) in diabetic nephropathy,41. 8% (62 cases) in focal segmental glomerulosclerosis, 39. 2% (246 cases) in IgA nephropathy,25.2% (41 cases) in lupus nephritis, 22.3% (37 cases) in membranous nephropathy, or 18.4% (100 cases) in minimal change disease and mesangial proliferative glomerulonephritis. There were statistically significant differences among the groups in the incidence of hypertension (χ² =163.309, P ＜0.001). The incidence of abnormal circadian rhythm of blood pressure in patients with different pathological types of CKD was 81. 6% (80 cases) in diabetic nephropathy, 64. 2% (95 cases) in focal segmental glomerulosclerosis,66.7% (419 cases) in IgA nephropathy, 58. 9% (96 cases) in lupus nephritis,51.8% (86 cases) in membranous nephropathy, or 52.9% (287 cases) in minimal change disease and mesangial proliferative glomerulonephritis. Among the groups, there were statistically significant differences in the incidence of abnormal circadian rhythm of blood pressure (χ² =48.087, P ＜0.001). (3) According to the IgA nephropathy Oxford scoring system,the score of renal arterioles was 0-1 (without arteriolar lesion)in 789 cases in which the incidence of hypertension was 10.6% (84 cases) and the incidence of abnormal circadian rhythm of blood pressure was 57.9% (457 cases),2-4 (mild renal arteriolar lesion) in 632 cases in which the incidence of hypertension was 35.4% (224 cases) and the incidence of abnormal circadian rhythm of blood pressure was 56% (354 cases), or 5-7 (severe renal arteriolar lesion) in 326 cases in which the incidence of hypertension was 77.3% (252 cases) and the incidence of abnormal circadian rhythm of blood pressure was 74.2% (242 cases). There were statistically significant differences between the above three scoring groups (χ² =475.8, χ² =219.647, P ＜0.001). Rank correlation analysis showed that the renal arteriolar lesion was more serious when the level of blood pressure was higher and the decline of nocturnal blood pressure was less.

Conclusions

The incidences of hypertension and abnormal circadian rhythm of blood pressure were higher in patients with chronic kidney disease, especially in patients with diabetic nephropathy or IgA nephropathy. The severity of renal arteriolar lesion in patients with chronic kidney disease was associated with both hypertension and abnormal circadian rhythm of blood pressure.