Medications to lower blood pressure in CKD. Hypertension in renal failure

High blood pressure is considered one of the main problems of the century, this indicator directly indicates the functionality of blood vessels and the heart. Patients who go to the hospital do not always know how the kidneys affect arterial pressure. Between them there is a pathogenetic relationship, the disease belongs to the secondary type of hypertension.

Kidney pressure - what is it

The considered pathology is diagnosed in 10-30% of cases with the development of hypertension. Kidney pressure - what is it? The disease develops with any pathology in the work of the kidneys. This organ in the human body is responsible for filtering arterial blood, removal of excess fluid, decay products of proteins, sodium, harmful substances that accidentally entered the circulatory system.

Increased pressure due to the kidneys appears when there is a violation in the work of the organ. Blood flow is reduced, sodium, water are retained inside, edema is formed. Sodium ions, accumulating, cause the walls of blood vessels to swell, which leads to an increase in their sensitivity. Kidney receptors begin to actively secrete the enzyme "renin", which turns into "angioteniz", then "aldosterone" is obtained from it. These substances affect the vascular tone, the gaps in them decrease, which leads to an inevitable increase in pressure.

Causes of nephrogenic arterial hypertension

The main task of the kidneys is to filter the blood, timely removal of water, sodium. Renal arterial hypertension begins to develop at the moment when the amount of incoming blood decreases. The vessels increase, the susceptibility to enzymes increases, at the same time the system is activated, which increases the production of aldosterone and sodium accumulates. This becomes a provoking factor in the growth of blood pressure and a decrease in the amount of prostaglandins that contribute to its reduction. Nephrogenic arterial hypertension - the causes of the development of this pathology:

• vascular injury;
• thrombosis, dysplasia, embolism, hypoplasia;
• anomaly of the aorta, parts of the urinary system;
• arteriovenous fistula;
• aneurysm;
• atherosclerosis of the artery;
• nephroptosis;
• arterial cysts, hematomas, compressed tumor;
• aortoarteritis.

kidney pressure symptoms

The disease begins, as a rule, suddenly, accompanied by an increase in blood pressure with pain in the lumbar spine. The tendency to this pathology can be inherited from parents. Even when taking medication to lower the pressure, relief does not occur. Renal hypertension manifests itself against the background of pathologies of the organ in question. The trigger mechanism can be: diabetes mellitus, pyelonephritis, glomerulonephritis. Renal pressure - the symptoms will necessarily be associated with the underlying pathology. The most common complaints are:

• urge to urinate more often than normal;
• increase in temperature of a periodic nature;
• pain in the lumbosacral region;
• general malaise, fatigue;
• increase daily allowance urine 2 times.

Treatment of renal hypertension

It is recommended to treat nephropathy comprehensively, it is necessary to establish the cause of the increase in pressure, eliminate it, and stop the symptoms. Renal hypertension - treatment can be carried out with the help of drugs (tablets, injections of solutions, etc.), folk remedies or through surgery. The last option is an extreme measure, which is necessary for congenital malformations or stenosis of the renal arteries. As a rule, balloon angioplasty or phonation of renal hypertension is performed.

How to lower kidney pressure at home

If the disease is at the initial stage and does not cause serious pain, disturbances in the functioning of the body, then you can treat yourself at home. First, you should consult with your doctor so that he assesses the degree of development of hypertension and tells you how to effectively lower kidney pressure at home. For these purposes, as a rule, diet therapy, infusions and herbs are used. folk recipes, light medications.

Pills for kidney failure

All therapy is aimed at lowering upper renal pressure, removing pain syndrome, to solve the main problem that provokes such a condition in the patient. The signs of PG themselves indicate the development of a disease that affects the kidneys. The specialist must determine the relationship between pathologies and prescribe the correct course of treatment. As a rule, the following tablets are used for kidney failure:

1. Antihypertensive drugs. Prazosin, Dopegyt, especially, have a good effect. with the secondary development of pressure in the kidneys. Medicines have a protective effect on the organ until it restores its functions.
2. Adrenoblockers, thiazide diuretics. Their reception implies the rejection of a number of products (diet without salt), therapy has a long duration without interruption. When developing a course of treatment, the size of the glomerular filtration rate should be taken into account; only a specialist can do this.

With the timely start of treatment, these medicines help regulate pressure (lower and upper). One of the main dangers of this pathology is that renal hypertension progresses very quickly, the brain and heart will be affected, so it is important to start treating the disease as quickly as possible. If the effectiveness of drug therapy is low, it is necessary to do balloon angioplasty.

Folk remedies

This is one type of therapy that may be approved by a doctor. The effectiveness of infusions, decoctions depends on the stage and degree of development of the disease. It is imperative to combine the treatment of kidney pressure with folk remedies with the right diet (eat food without salt, give up alcohol, etc.). You can regulate the pressure using the following recipes:

1. Bearberry infusion. Take 2 tbsp. l. crushed plant, pour into a glass of boiling water. The infusion will be ready in 30 minutes. Drink it 4 times a day for 20 ml.
2. The next recipe is a collection of 5 tbsp. l. flax seeds, 2 tbsp. l. birch leaves, 1 tbsp. l. blackberry and strawberry leaves. Use a coffee grinder to grind all the ingredients, you should get a powder. Take 2 tbsp. l. finished mass for 0.5 liters of boiling water. The remedy should be infused for 7 hours, then take 5 times a day for 3 weeks. Then you should take a break for 7 days and continue taking the folk medicine.
3. The next infusion for the treatment of renal hypertension is prepared from 3 tbsp. l. carrot seeds, which should be ground in advance in a coffee grinder or blender. Place them in a thermos, fill with boiling water and leave for 10 hours. Strain the resulting composition and drink before meals 1 glass 5 times a day. The course of treatment lasts 14 days.

The complex relationship between systemic hypertension and the kidneys, aggravated against the background of existing renal pathology, determines the features of antihypertensive therapy in kidney diseases.

Row general provisions on which the treatment of hypertension is based - the regime of work and rest, weight loss, reduction in alcohol consumption, increase physical activity, adherence to a diet with a restriction of salt and foods containing cholesterol, the abolition of drugs that cause the development of hypertension - retain their importance in the treatment of PH.

Of particular importance for nephrological patients is severe sodium restriction. Bearing in mind the role of sodium in the pathogenesis of hypertension, as well as the violation of sodium transport in the nephron, which is characteristic of renal pathology, with a decrease in its excretion and an increase in the total sodium content in the body, daily salt intake in nephrogenic hypertension should be limited to 5 g / day, which, taking into account the high sodium content in finished food products (bread, sausages, canned food, etc.) practically eliminates the additional use of salt in cooking. Salt restriction should be less severe in patients with polycystic kidney disease, "salt-losing" pyelonephritis, in some variants of the course of chronic renal failure, when, due to damage to the renal tubules, sodium reabsorption in them is impaired and sodium retention in the body is not observed. In these situations, the criterion for determining the patient's salt regimen is the daily excretion of Na and the volume of circulating blood. In the presence of hypovolemia and / or with increased excretion of sodium in the urine, salt intake should not be limited.

Much attention is currently being paid to the tactics of antihypertensive therapy - the rate of reduction in blood pressure, establishing the level of blood pressure to which the initially elevated blood pressure should be reduced, and also the question of whether “mild” hypertension (BP diast. 95-105 mm Hg) requires permanent antihypertensive treatment .).

Based on the observations made, the following is now considered proven:

The single-stage maximum decrease in elevated blood pressure should not exceed 25% of the initial level, so as not to impair renal function;

In patients with kidney pathology and AH syndrome, antihypertensive therapy should be aimed at the complete normalization of blood pressure, even despite a temporary decrease in the depurative function of the kidneys. This tactic is designed to eliminate systemic hypertension and thus intraglomerular hypertension as the main non-immune factors in the progression of renal failure and suggests a further improvement in renal function;

- "Mild" AT in nephrological patients requires constant antihypertensive treatment in order to normalize intrarenal hemodynamics and slow down the progression of renal failure.

A feature of the treatment of hypertension in chronic kidney disease is the need to combine antihypertensive therapy with pathogenetic therapy of the underlying disease. Means of pathogenetic therapy of kidney diseases (glucocorticosteroids, heparin, chimes, non-steroidal anti-inflammatory drugs, sandimmun) themselves can have a different effect on blood pressure, and their combination with antihypertensive drugs can nullify or enhance the hypotensive effect of the latter.

Hypertension is a contraindication to the appointment of high doses of glucocorticosteroids, except in cases of rapidly progressive glomerulonephritis. In patients with moderate nephrogenic AH, glucocorticosteroids can increase it if, when administered, a pronounced diuretic and natriuretic effect does not develop, which is usually observed in patients with initial severe sodium retention and hypervolemia.

Non-steroidal anti-inflammatory drugs(NSPP) - indomethacin, ibuprofen, etc. - are inhibitors of prostaglandin synthesis. A number of studies, including ours, have shown that NSAIDs can have antidiuretic and antinatriuretic effects and increase blood pressure, which limits their use in the treatment of patients with nephrogenic hypertension. The appointment of NSPP simultaneously with antihypertensive drugs can either neutralize the effect of the latter, or significantly reduce their effectiveness. In contrast to these drugs, heparin has a diuretic, natriuretic and hypotensive effect. The drug enhances the hypotensive effect of other medicines. Our experience suggests that the simultaneous administration of heparin and antihypertensive drugs requires caution, as it can lead to a sharp decrease in blood pressure. In these cases, it is advisable to start heparin therapy with a small dose (15-17.5 thousand units / day) and increase it gradually under the control of blood pressure. In the presence of severe renal insufficiency (glomerular filtration rate less than 35 ml / min), heparin in combination with antihypertensive drugs should be used with great caution.

The selection of antihypertensive drugs and the selection of the most preferred ones for the treatment of nephrogenic hypertension are based on the following principles:

The drugs should affect the pathogenetic mechanisms of the development of hypertension;

Use drugs that do not reduce blood supply to the kidneys and do not depress renal function;

Use drugs that can correct intraglomerular hypertension;

Use drugs that do not cause metabolic disorders and

With minimal side effects.

Start treatment with small doses of drugs, gradually increasing them until a therapeutic effect is achieved.

Antihypertensive (antihypertensive) drugs. Currently, 5 classes of antihypertensive drugs are used to treat patients with nephrogenic arterial hypertension:

ACE inhibitors;

calcium antagonists;

B-blockers;

diuretics;

A blockers.

Drugs of the central mechanism of action (drugs of rauwolfia, a-methyldopa, clonidine) are of auxiliary importance and are currently used only for narrow indications.

First-choice drugs include angiotensin-converting enzyme (ACE) inhibitors and calcium channel blockers (calcium antagonists).

These two groups of drugs meet all the requirements for antihypertensive drugs intended for the treatment of nephrogenic arterial hypertension and, which is especially important, simultaneously possess nephroprotective properties.

ACE inhibitors are a class of antihypertensive drugs pharmacological action which is the inhibition of angiotensin-converting enzyme (aka kininase II).

The physiological effects of angiotensin-converting enzyme are twofold. On the one hand, it converts angiotensin I to angiotensin II, which is one of the most powerful vasoconstrictors. On the other hand, being kininase II, it destroys kinins, tissue vasodilating hormones. Accordingly, pharmacological inhibition of this enzyme blocks the systemic and organ synthesis of angiotensin II and accumulates kinins in the circulation and tissues.

Clinically, these effects are manifested:

A pronounced hypotensive effect, which is based on a decrease in general and local renal peripheral resistance;

Correction of intraglomerular hemodynamics, which is based on the expansion of the efferent renal arteriole - the main site of application of local renal angiotensin II.

In recent years, the renoprotective role of ACE inhibitors has been actively discussed, which is associated with the elimination of the effects of angiotensin, which determine the rapid sclerosis of the kidneys, i.e. with blockade of the growth of mesangial cells, their production of collagen and epidermal growth factor of the renal tubules.

In table. 8.2 shows the most common ACE inhibitors with their dosages.

Depending on the time of excretion from the body, first-generation ACE inhibitors are isolated (captopril - with an elimination half-life of less than 2 hours and a hemodynamic effect duration of 4-5 hours) and second-generation ACE inhibitors with a drug half-life of 11-14 hours and a hemodynamic effect duration of more than 24 hours To maintain the optimal concentration of drugs in the blood during the day, a 4-fold dose of captopril and a single (sometimes double) dose of other ACE inhibitors are required.

Renal effects of ACE inhibitors. The effect of all ACE-Is on the kidneys is almost the same. Our experience of long-term use of ACE inhibitors (captopril, renitec, tritace) in nephrological patients with arterial hypertension indicates that, with initially preserved renal function, ACE inhibitors with their long-term use (months, years) increase renal blood flow, do not change or slightly reduce creatinine blood, increasing GFR. In the very initial periods of treatment with ACE inhibitors (the first week), a slight increase in blood creatinine and potassium levels in the blood is possible, which independently return to normal levels within the next few days without discontinuing the drug.
Risk factors for a stable decline in renal function are the elderly and senile age of patients. The dose of ACE inhibitors in this age group should be reduced.

ACE inhibitor therapy in patients with renal insufficiency requires special attention. In the vast majority of patients, long-term ACE-i therapy adjusted for the degree of renal failure has a beneficial effect on renal function: creatininemia decreases, GFR increases, and the onset of end-stage renal failure slows down. In the observations of A.-L.Kamper et al. 7-year continuous treatment with enalapril in patients with severe CRF (initial GFR averaged 25 ml/min) slowed down the onset of end-stage renal disease in 12 of 35 patients (34%), which is 2.5 times higher than the number of patients (5 of 35) who received traditional antihypertensive therapy. AIPRI, a prospective, randomized, multicenter study that ended in 1996, also confirmed the ability of ACE-i to slow the progression of kidney failure. Of 300 patients with severe chronic renal failure treated with ACE inhibitor benazepril for 3 years, hemodialysis or kidney transplantation was required in 31 patients, while in the comparison group of 283 patients treated with placebo, such a need developed in 57 patients; during the continuation of the study (after 6.6 years), terminal renal failure in the group receiving ACE inhibitors developed in 79 people, while in the comparison group - in 102. However, the increase that persisted for 10-14 days from the start of ACE inhibitor therapy blood creatinine and hyperkalemia is an indication for discontinuation of the drug.

ACE inhibitors have the ability to correct intrarenal hemodynamics, reducing intrarenal hypertension and hyperfiltration. In our observations, correction of intrarenal hemodynamics under the influence of renitec was achieved in 77% of patients.

ACE inhibitors have a pronounced antiproteinuric property.

The maximum antiproteinuric effect develops against the background of a low-salt diet. Increased salt intake leads to loss of antiproteinuric properties of ACE-I.

Complications and side effects of ACE inhibitors. ACE inhibitors are a relatively safe group of drugs. They have few side effects.

The most common complications are cough and hypotension. Cough can occur at different times of treatment with drugs - both at the earliest and after 20-24 months from the start of therapy. The mechanism of cough occurrence is associated with the activation of kinins and prostaglandins. The reason for the abolition of drugs in the event of a cough is a significant deterioration in the quality of life of the patient. After discontinuation of the drugs, the cough disappears within a few days.

A more severe complication of ACE inhibitor therapy is the development of hypotension. The risk of its occurrence is high in patients with congestive heart failure, especially in the elderly; with malignant high-renin arterial hypertension, with renovascular arterial hypertension. Important for the clinician is the ability to predict the development of hypotension during the use of ACE inhibitors. For this purpose, the hypotensive effect of the first low dose of the drug (12.5-25 mg of capoten; 2.5 mg of renitec; 1.25 mg of tritace) is evaluated. A pronounced hypotensive response to this dose may predict the development of hypotension with long-term treatment drugs. In the absence of a pronounced hypotensive response, the risk of developing hypotension with further treatment is significantly reduced.

Quite frequent complications of treatment with ACE inhibitors are headache, dizziness. These complications usually do not require discontinuation of drugs.

In nephrological practice, contraindications to the use of ACE inhibitors are:

Stenosis of the renal artery of both kidneys;

Stenosis of the renal artery of a single kidney (including a transplanted kidney);

The combination of renal pathology with severe heart failure;

Severe chronic renal failure, long-term treatment with diuretics.

The appointment of ACE inhibitors in these cases can be complicated by an increase in blood creatinine, a drop in glomerular filtration up to the development of acute renal failure.

ACE inhibitors are contraindicated during pregnancy, since their use in the II and III trimesters could lead to fetal hypotension, malformations, malnutrition and death.

calcium antagonists. The mechanism of the hypotensive action of calcium antagonists (AK) is associated with the expansion of arterioles and a decrease in elevated TPS due to inhibition of the entry of Ca2+ ions into the cell. The ability of drugs to block the vasoconstrictor effect of the endothelial hormone, endothelin, has also been proven.

The modern classification of calcium antagonists (AK) distinguishes three groups of drugs:

1) papaverine derivatives (verapamil, thiapamil);

2) dihydropyridine derivatives (nifedipine, nitrendipine, nisoldipine, nimodipine);

3) benzothiazepine derivatives - diltiazem. They are called prototype drugs, or

AK 1st generation. According to antihypertensive activity, all three groups of prototype drugs are equivalent, i.e. the effect of nifedipine at a dose of 30-60 mg/day is comparable to the effects of verapamil at a dose of 240-480 mg/day and diltiazem at a dose of 240-360 mg/day.

In the 80s, AK 2nd generation appeared. Their main advantages were the long duration of action, good tolerability and tissue specificity. In table. 8.3 presents the most common drugs of these two groups.

In terms of antihypertensive activity, AKs represent a group of highly effective drugs. The advantages over other antihypertensive drugs are their pronounced anti-sclerotic (drugs do not affect the blood lipoprotein spectrum) and antiaggregation properties. These qualities make them the drugs of choice for the treatment of the elderly.

Renal effects of calcium antagonists. Calcium antagonists have a beneficial effect on renal function: they increase renal blood flow and cause natriuresis. Less clear is the effect of drugs on glomerular filtration rate and intrarenal hypertension. There is evidence that verapamil and diltiazem reduce intraglomerular hypertension, while nifedipine either does not affect it or increases intraglomerular pressure. In this regard, for the treatment of nephrogenic hypertension among drugs of the AK group, preference is given to verapamil and diltiazem and their derivatives.

All AKs have a nephroprotective effect, which is determined by their ability to reduce renal hypertrophy, inhibit metabolism and mesangial proliferation, and thus slow down the rate of progression of renal failure.

Complications and side effects of calcium antagonists. Side effects are usually associated with taking the AK group of short-acting dihydropyridine - 4-6 hours. The half-life ranges from 1.5 to 4-5 hours. Within a short time, the concentration of nifedipine in the blood varies over a wide range - from up to 5-10 ng / ml. A poor pharmacokinetic profile with a peak increase in the concentration of the drug in the blood, entailing a drop in blood pressure for a short time and a number of neurohumoral reactions, such as the release of catecholamines, activation of the RAS and other "stress hormones", determines the main adverse reactions when taking drugs (tachycardia, arrhythmia, steal syndrome with exacerbation of angina pectoris, facial flushing and other symptoms of hypercatecholaminemia), which are unfavorable for the function of the heart and kidneys.

Long-acting and continuous release nifedipine (GITS form) provides for a long time a constant concentration of the drug in the blood, and therefore they are devoid of the above adverse reactions and can be recommended for the treatment of nephrogenic hypertension.

Due to the cardiosuppressive effect, verapamil can cause bradycardia, atrioventricular block and in rare cases(with heart failure in the case of high doses) - atrioventricular dissociation. When taking verapamil, constipation often develops.

Although AKs do not cause negative metabolic effects, the safety of their use in early period pregnancy has not yet been established.

Reception of calcium antagonists is contraindicated in initial hypotension, weakness syndrome sinus node. Verapamil is contraindicated in atrioventricular conduction disorders, sick sinus syndrome, severe heart failure.

D-adrenergic receptor blockers are included in the spectrum of drugs intended for the treatment of PH.

The mechanism of the antihypertensive action of blockers is associated with a decrease in cardiac output, inhibition of renin secretion by the kidneys, a decrease in OPS, a decrease in the release of norepinephrine from the endings of postganglionic sympathetic nerve fibers, a decrease in venous inflow to the heart and circulating blood volume. In table. 8.4 presents the most common drugs in this group.

There are non-selective β-blockers (blocking both β1-, β2-adrenergic receptors) and cardioselective, blocking predominantly β1-adrenergic receptors. Some of these drugs (oxprenolol, pindolol, acebutolol, talinolol) have sympathomimetic activity, which makes it possible to use them in heart failure, bradycardia, and in patients with bronchial asthma.

According to the duration of action, short-acting β-blockers (propranolol, oxprenolol, metaprolol, apebutalol), intermediate (pindolol) and long-term (atenolol, betaxolol, sotalol, napolol) action are distinguished.

A significant advantage of this group of drugs is their antianginal properties, the possibility of preventing the development of myocardial infarction, reducing or slowing down the development of myocardial hypertrophy.

Renal effects of β-blockers. The drugs do not cause oppression of the renal blood supply and reduce renal function. With long-term treatment, the glomerular filtration rate, diuresis and sodium excretion remain within the initial values. When treated with high doses of drugs, PAAC is blocked and hyperkalemia may develop.

Side effects of P-blockers. Severe sinus bradycardia (heart rate less than 50 per minute), arterial hypotension, increased left ventricular failure, atrioventricular blockade of varying degrees, exacerbation of bronchial asthma or other chronic obstructive pulmonary disease, hypoglycemia (especially in patients with labile diabetes mellitus) may develop; exacerbation of intermittent claudication and Raynaud's syndrome; development of hyperlipidemia; in rare cases, there is a violation of sexual function.

β-Adrenergic blockers are contraindicated in acute and chronic heart failure, severe bradycardia, sick sinus syndrome, atrioventricular block II and III degree, bronchial asthma and severe broncho-obstructive diseases.

Diuretics. Diuretics are drugs specifically designed to remove sodium and water from the body. The essence of the action of all diuretic drugs is reduced to blockade of sodium reabsorption and a consistent decrease in water reabsorption during the passage of sodium through the nephron.

The hypotensive effect of natriuretics is based on a decrease in BCC and cardiac output due to the loss of part of the exchangeable sodium and a decrease in OPS due to a change in the ionic composition of the walls of arterioles (sodium output), as well as a decrease in their sensitivity to pressor vasoactive hormones. In addition, during combined therapy with antihypertensive drugs, diuretics can block the sodium-retaining effect of the main antihypertensive drug, potentiate the hypotensive effect, and the salt regimen can be slightly expanded, making the diet more acceptable for patients.

For the treatment of PH in patients with preserved renal function, diuretic drugs acting in the area of ​​the distal tubules are most widely used - a group of thiazide (hypothiazide, ezidrex) and thiazide-like diuretics, such as indapamide (arifon).

Small doses are used to treat AT hypothiazide- 12.5-25 mg 1 time per day. The drug is excreted unchanged through the kidneys. Hypothiazide has the ability to reduce the glomerular filtration rate, and therefore its use is contraindicated in renal failure - blood creatinine levels of more than 2.5 mg%, GFR less than 30 ml / min.

Indapamide (arifon)- a new antihypertensive agent of the diuretic series. Due to its lipophilic properties, Arifon is selectively concentrated in the vascular wall and has a long half-life - 18 hours. The hypotensive dose of the drug is 2.5 mg of Arifon 1 time per day. The mechanism of its hypotensive action is associated with the ability of the drug to stimulate the production of prostacyclin and thereby cause a vasodilating effect, as well as with the ability to reduce the content of free intracellular calcium, which ensures less sensitivity of the vascular wall to the action of pressor amines.

The diuretic effect of the drug develops against the background of taking large therapeutic doses (up to 40 mg of Arifon per day).

For the treatment of PG in patients with impaired renal function and diabetes mellitus, diuretics are used that act in the loop of Henle, - loop diuretics. From loop diuretics to clinical practice the most common are furosemide (lasix), ethacrynic acid (uregit), bumetanide (burinex).

Furosemide has a powerful natriuretic effect. In parallel with the loss of sodium, the use of furosemide increases the excretion of potassium, magnesium and calcium from the body. The period of action of the drug is short - 6 hours, the diuretic effect is dose-dependent. The drug has the ability to increase the glomerular filtration rate, and therefore is indicated for patients with renal insufficiency.

Furosemide is prescribed at 40-120 mg per day orally, intramuscularly or intravenously up to 250 mg per day.

Side effects of diuretics. Among side effects all diuretic drugs highest value has hypokalemia (more pronounced when taking thiazide diuretics). Correction of hypokalemia is especially important in patients with hypertension, since potassium itself helps to reduce blood pressure. With a decrease in potassium below 3.5 mmol / l, potassium-containing drugs should be added. Among the others side effects hyperglycemia (thiazides, furosemide), hyperuricemia (more pronounced with the use of thiazide diuretics), the development of dysfunction of the gastrointestinal tract, and impotence are of importance.

a-adrenergic blockers. Of this group of antihypertensive drugs, prazosin (pratsiol, minipress, adverzuten) has become the most widely used in recent years. new drug- doxazosin (cardura).

Prazosin (pratsiol, minipress, adverzuten) - selective antagonist presynaptic receptors. The hypotensive effect of the drug is associated with a direct decrease in OPS. Prazosin expands the venous bed, reduces preload, which justifies its use in patients with heart failure.

The hypotensive effect of prazosin when taken orally occurs after 1/2-3 hours and persists for 6-8 hours. The half-life is 3 hours. The drug is excreted through gastrointestinal tract, and therefore no dose adjustment is required in renal failure.

The initial therapeutic dose of prazosin is 0.5-1 mg / day; within 1-2 weeks, the dose is increased to 3-20 mg / day (in 2-3 doses). The maintenance dose is 5-7.5 mg / day.

Prazosin has a positive effect on kidney function - it increases renal blood flow, the amount of glomerular filtration. The drug has hypolipidemic properties, has little effect on electrolyte metabolism. These properties contribute to the appointment of the drug in chronic renal failure.

As side effects postural hypotension, dizziness, drowsiness, dry mouth, impotence were noted.

Doxazosin (cardura) structurally close to prazosin, but has a long-term effect. The drug significantly reduces OPS. The great advantage of doxazosin is its beneficial effect on metabolism. The drug has pronounced anti-atherogenic properties - it lowers cholesterol, LDL and VLDL cholesterol, increases HDL. At the same time, no negative effect on carbohydrate metabolism. These properties make doxazosin the drug of choice in the treatment of hypertension in patients diabetes.

Doxazosin, like prazosin, has a beneficial effect on renal function, which determines its use in patients with PH in the stage of renal failure.

When taking the drug, the peak concentration in the blood occurs after 2-4 hours; the half-life ranges from 16 to 22 hours. Therapeutic doses - 1-8 mg 1 time per day.

Side effects include dizziness, nausea, headache, and in the elderly - hypotension.

Treatment of arterial hypertension in the stage of chronic renal failure. The development of severe CRF (GFR 30 ml/min and below) makes its own adjustments to the treatment of hypertension. In chronic renal failure, as a rule, complex therapy of hypertension is required, including salt restriction in the diet without fluid restriction, removal of excess sodium with the help of saluretics and the use of effective antihypertensive drugs and their combinations.

Of the diuretics (saluretics), furosemide and ethacrynic acid are the most effective, the dose of which can be increased to 300 and 150 mg / day, respectively. Both drugs slightly increase GFR and significantly increase potassium excretion. They are usually prescribed in tablets, and in urgent conditions (pulmonary edema) - intravenously. When using large doses, one should be aware of the possibility of ototoxic effects. Due to the fact that hyperkalemia often develops simultaneously with sodium retention in chronic renal failure, potassium-sparing diuretics are rarely used and with great care. Thiazide diuretics (hypothiazide, cyclometazide, oxodoline, etc.) are contraindicated in chronic renal failure. Calcium antagonists are one of the main groups of antihypertensive drugs used in chronic renal failure. The drugs favorably affect renal blood flow, do not cause sodium retention, do not activate the RAS, do not affect lipid metabolism. A combination of drugs with β-blockers, centrally acting sympatholytics is often used (for example, corinfar + anaprilin + dopegyt, etc.).

In severe, refractory to treatment and malignant hypertension, patients with chronic renal failure are prescribed ACE inhibitors (captopril, renitec, tritace, etc.) in combination with saluretics and β-blockers, but the dose of the drug should be reduced, taking into account the decrease in its release as chronic renal failure progresses . Constant monitoring of GFR and the level of azotemia is necessary, since with the predominance of the renovascular mechanism of AT, filtration pressure in the glomeruli and GFR can sharply decrease.

With the ineffectiveness of drug therapy, extracorporeal methods for removing excess sodium are indicated: isolated ultrafiltration, hemodialysis (HD), hemofiltration. The tactics of treating PH in patients treated with hemodialysis and after kidney transplantation are described in detail in the relevant sections of the manual. We will focus on general provisions.

In the terminal stage of chronic renal failure after switching to program HD, the treatment of volume-sodium-dependent hypertension consists in maintaining an adequate HD and ultrafiltration regimen and an appropriate water-salt regimen in the inter-dialysis period to maintain the so-called dry weight. If additional antihypertensive treatment is needed, calcium antagonists or sympatholytics are used. In severe hyperkinetic syndrome, in addition to the treatment of anemia and surgical correction of arteriovenous fistula, it is useful to use β-blockers in small doses. At the same time, since the pharmacokinetics of β-blockers in chronic renal failure is not disturbed, and large doses of them suppress renin secretion, these same drugs are also used in the treatment of renin-dependent AT in combination with vasodilators and sympatholytics.

More effective in AT not controlled by HD are often β-+α-blockers, calcium antagonists, and especially ACE-I, and it must be taken into account that captopril is actively excreted during the HD procedure (up to 40% for a 4-hour HD). In the absence of the effect of antihypertensive therapy in preparing a patient for a kidney transplant, bilateral nephrectomy is used to convert renin-dependent uncontrolled hypertension into a renoprival volume-sodium-dependent controlled form.

In the treatment of hypertension that develops again in patients on HD and after kidney transplantation (KT), it is important to identify and eliminate the causes: dose adjustment of drugs that contribute to hypertension (erythropoietin, corticosteroids, sandimmune), surgery transplant artery stenosis, resection of parathyroid glands, tumors, etc. In the pharmacotherapy of hypertension after LT, calcium antagonists and ACE inhibitors are primarily used, and diuretics are treated with caution, since they increase lipid metabolism disorders and may contribute to the formation of atherosclerosis, which is responsible for a number of complications after LT.

In conclusion, it can be stated that at the present stage there are great opportunities for the treatment of PH at all stages of its development: with intact kidney function, at the stage of chronic and terminal renal failure, in the treatment of programmatic HD and after kidney transplantation. The choice of antihypertensive drugs should be based on a clear understanding of the mechanisms of development of hypertension and clarification of the leading mechanism in each case.

Kidney disease can cause secondary hypertension, which is called hypertension in renal failure. The peculiarity of this condition is that, together with nephropathy, the patient has high values ​​of systolic and diastolic pressure. Treatment of the disease is long. Arterial hypertension of any origin is a common cardiovascular disease and occupies 94-95% of them. The share of secondary hypertension accounts for 4-5%. Among secondary hypertension, renovascular hypertension is the most common and accounts for 3-4% of all cases.

Where is the connection?

emergence arterial hypertension in chronic renal failure (chronic renal failure) is due to changes in the normal functioning of the organs of the urinary system, in violation of the mechanism of blood filtration. In this case, excess fluid and toxic substances (sodium salts and protein breakdown products) cease to be excreted from the body. Excess water accumulated in the extracellular space provokes the appearance of edema internal organs, arms, legs, face.

From a large amount of fluid, the renal receptors are irritated, the production of the enzyme renin, which breaks down proteins, increases. In this case, there is no increase in pressure, but interacting with other blood proteins, renin promotes the formation of angiotensin, which promotes the formation of aldosterone, which retains sodium. The result is an increase in tone. renal arteries and the process of formation of cholesterol plaques, narrowing the cross section of blood vessels, is accelerated.

In parallel, the content of derivatives of polyunsaturated fatty acids and bradykinin, which reduce the elasticity of blood vessels, decreases in the kidneys. As a result, in hypertension of renovascular origin, high blood pressure is persistent. Hemodynamic disorder leads to cardiomyopathy (left ventricular hypertrophy) or other pathological conditions of cardio-vascular system.

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Reasons for the development of renal failure with blood pressure

The most common cause of the development of the disease is pyelonephritis.

The functioning of the renal arteries is impaired in nephropathology. A common cause of nephrogenic arterial hypertension is arterial stenosis. Narrowing of the section of the renal arteries due to thickening muscle walls seen in young women. In older patients, the narrowing appears due to atherosclerotic plaques that impede the free flow of blood.

Factors that provoke high blood pressure in nephropathies can be divided into 3 groups - negative changes in the parenchyma (kidney membrane), damage to blood vessels and combined pathologies. The causes of diffuse pathologies of the parenchyma are:

• pyelonephritis;
• glomerulonephritis;
• lupus erythematosus;
• diabetes;
• urolithic pathologies;
• congenital and acquired anomalies of the kidneys;
• tuberculosis.

Among the causes of vasorenal hypertension associated with the state of the blood vessels, note:

• atherosclerotic manifestations in the older age group;
• anomalies in the formation of blood vessels;
• tumors;
• cysts;
• hematomas.

Nephrogenic hypertension is very resistant to medications that lower blood pressure.

Characteristic nephrogenic hypertension - the ineffectiveness of drugs that reduce blood pressure, even in the case of high values. Provoking factors can have a negative impact both singly and in any combination of damage to the parenchyma and blood vessels. In this situation, it is very important to identify existing problems in a timely manner. For patients diagnosed with renal insufficiency, dispensary observation doctor. A competent specialist will be able to choose complex therapy for the underlying pathology and medications to reduce blood pressure.

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Course of the disease

Doctors distinguish two types of the course of the disease: benign and malignant. Benign type of renal hypertension develops slowly, and malignant quickly. Main symptoms various kinds renal hypertension is listed in the table:

The disease can cause poor blood flow in the brain.

Arterial hypertension in pathological conditions of the kidneys provokes the following problems:

• violation of the blood flow of the brain;
• changes in blood biochemical parameters (low hemoglobin and red blood cells, platelets, leukocytosis and increased ESR);
• hemorrhage in the eye;
• violation of lipid metabolism;
• damage to the vascular endothelium.

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Symptoms of pathology

Symptoms of nephrogenic hypertension and arterial hypertension are similar:

• high blood pressure numbers;
• headache;
• aggressiveness;
• low work capacity;
• increased heart rate.

Signs of high blood pressure associated with a pathological condition of the kidneys are:

• the appearance of pathology at a young age (up to 30 years);
• pain in the lumbar region;
• a sharp increase in blood pressure without active physical exertion;
• different pressure in the right and left limbs;
• pastosity of the limbs;
• retinopathy.

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Treatment and its features

Treatment is primarily aimed at stabilizing the functioning of the kidneys.

The complex of therapeutic measures for nephrogenic hypertension is aimed at solving the following problems - stabilizing kidney function, restoring normal hemodynamics and lowering blood pressure. To solve these problems, use drug therapy, hardware treatment and surgical methods. Therapy for lowering blood pressure is aimed at a mild decrease in blood pressure levels.

Patients with a history of diseases of the urinary system should take antihypertensive drugs, despite the deterioration in the excretion of end products of nitrogen metabolism. Requires consideration, the fact that in diseases of the kidneys use basic therapy that affects the level of blood pressure. Drugs can enhance the effect of an antihypertensive drug or inhibit it. An important condition for therapeutic measures is the appointment of complex action medications with the least side effects.

Among the hardware, phonation is the most popular. The impact of sound waves contributes to:

• normalization of kidney function;
• increased excretion of uric acid;
• destruction of sclerotic plaques;
• normalization of blood pressure.

Surgery for renovascular hypertension can be used in the presence of tumors that interfere with the normal functioning of the organ. With stenosis of the adrenal artery, a balloon angioplasty is performed. Thanks to this operation, blood flow improves, the walls of blood vessels are strengthened and pressure is reduced. An extreme measure for the correction of renovascular hypertension is nephrectomy or kidney resection.

Chronic hypertension - symptoms and treatment of the disease

Chronic hypertension is a common disease accompanied by high blood pressure that obstructs blood flow. The danger of the disease lies in its detrimental effect on the work of most internal organs. To avoid the risk of complications will allow timely detection and competent treatment according to the scheme prescribed by doctors. In addition to high blood pressure, chronic hypertension is accompanied by other symptoms.

For successful treatment chronic disease strict adherence to medical prescriptions is required, because a process stopped halfway through threatens the development of a hypertensive crisis with a pressure jump a quarter higher than normal.

The disease can be caused by malnutrition with excessive consumption of salty foods and fast food, as well as smoking, drinking alcohol, stressful conditions, psycho-emotional overstrain and physical inactivity. Persons with severe weather dependence are most often affected by chronic hypertension - with seasonal changes in the weather, pressure indicators increase significantly and severe malaise is observed.

Signs of the disease

At the very beginning, an attack of hypertension may not be noticed - a slight malaise appears, which is mistakenly perceived as a consequence of overwork. As the disease progresses and the incidence of high blood pressure increases, the symptoms increase. Distinguish the main symptoms of the disease and additional.

Main symptoms

The most common manifestations of the disease include headache, throbbing in the back of the head and temples, aggravated during body movements. Headache is accompanied by darkening of the eyes and dizziness. The manifestation of this symptom is not associated with a specific time of day, but more often the pain occurs at night and early morning hours. There is a characteristic bursting, heaviness in the back of the head and other places. Strengthening of the symptom is observed with coughing, bending over, straining, with the appearance of swelling of the face. Pain reduction occurs as the outflow of blood in the veins improves with an upright position, muscle activity, and massage.

The most common complaints when visiting a doctor include the appearance of special noises in the head and problems with memory. Chronic patients often experience various sleep disorders, insomnia. Depending on the severity of the symptoms (one of the main indicators is blood pressure), there are various forms of the disease.

A sign of the presence of severe lesions of the heart muscle is shortness of breath, which occurs even when the patient is at rest.

Often, chronic arterial hypertension is accompanied by a deterioration in vision, expressed in a decrease in clarity, a cloudy appearance of objects.

There are several stages of this disease, expressed in an increase in pressure under various circumstances:

• the first degree - in stressful situations, the pressure rises sharply within 160/100 mm Hg, and after a while it normalizes without the use of any drugs;
• the second degree - high blood pressure at the level of 180/110 mm Hg. fixed at different times of the day in various states of the patient with a possible further decrease;
• third degree - in addition to high pressure exceeding 180/110 mm Hg, there are additional signs of the disease with the detection of pathologies of the heart, eyes, brain, kidneys.

Additional symptoms

Associated manifestations of the disease include:

• distraction;
• nervousness;
• memory problems;
• nosebleeds;
• general weakness;

• numbness and swelling of the limbs;
• heart pain;
• sweating;
• speech disorder.

The disease can proceed unnoticed for most patients for years, expressed from time to time by a feeling of weakness, which, combined with dizziness, is mistaken for overwork. Such signs require special attention and measurement of blood pressure levels. If the increasing symptoms are ignored, a cerebral infarction may result.

Physical examination of the heart may show left ventricular hypertrophy with thickening of the cardiomyocytes. Starting with the process of thickening along the wall of the left ventricle, an increase in the size of the heart chamber is observed. This manifestation indicates a growing danger sudden death or heart failure, ischemic heart disease, and ventricular arrhythmias. This picture is complemented by shortness of breath when performing activities with exercise, cardiac asthma (paroxysmal shortness of breath), pulmonary edema, heart failure and other heart problems.

Examination by a doctor also shows gross morphological changes in the aorta, its expansion, dissection and rupture. There is a lesion of renal activity with the appearance of protein in the analysis of urine, microhematuria, cylindria.

How is the disease diagnosed?

Diagnosis involves the use of a set of measures aimed at studying the manifestations, establishing the root causes and complications that have arisen.

Collecting anamnesis data from the patient

If characteristic symptoms appear, you should consult a doctor. The first step in the examination is to take a history. The following factors May be indicative of chronic hypertension

1. Hereditary predisposition to hypertension, heart attacks, strokes, gout.
2. The presence of relatives suffering from hypercholesterolemia.
3. The presence among relatives of patients with diabetes mellitus, renal pathologies.
4. Overweight.
5. Smoking.
6. Alcohol abuse.
7. Constant physical or mental overload.
8. Regular use of drugs that can provoke a sharp increase in pressure.

After identifying these circumstances, a medical examination is performed.

Blood pressure measurement

At the stage of medical examination, pressure measurements are taken. Systolic and diastolic indicators are taken in full accordance with the measurement rules, because. even the slightest violation can cause distortion of indicators: before taking measurements, the patient needs a state of rest for several minutes. Measurements are performed on the hands alternately with a permissible discrepancy of up to 10 points. If necessary, the procedure is repeated, after at least one hour. This measure is applied if the indicators are from 140/90.

In addition to measuring pressure, the doctor performs a complete examination of the patient, which allows him to assess his condition and clarify the symptoms and causes, followed by the appointment of a treatment regimen:

1. It is necessary to listen to the lungs and heart to identify pathologies of the heart.
2. The necessary measurements are made to determine the ratio of a person’s height to his weight with the possible identification of a tendency to be overweight.
3. Examination and palpation of the abdominal cavity to assess the functioning of the kidneys.

After inspection, they are assigned laboratory research and instrumental diagnostics.

Medical tests

There are primary and secondary methods of laboratory research.

First of all, the doctor prescribes analytical screening, represented by blood and urine tests (general and specific, aimed at detecting pathologies).

Information obtained through diagnosis, anamnesis, examination will reveal the causes and pathologies that contribute to the development of the disease.

Instrumental diagnostics

During the examination, medical diagnostic equipment is used to assess the condition and functioning of the cardiac and renal systems.

An electrocardiogram (consists of 12 measurements) reveals abnormalities in the work of the heart against the background of problems with blood pressure, or vice versa.

The pathology of the cardiac departments can be detected by radiography.

Ultrasound of the kidneys and adrenal glands is also prescribed to visually detect dysfunction. results ultrasound help to determine the influence of the renal nature of hypertension.

An ophthalmological examination of the fundus is indicated because of the risk of increased eye pressure.

For most situations, these types of examinations are sufficient to establish the fact of the disease, however, other methods are used to accurately assess and prescribe treatment.

Additional Methods

A complete picture of the disease will allow you to get the following methods:

• echocardiogram (allows you to assess the risk and clarify the treatment regimen);
• computer diagnostics (tomogram or MRI) of the brain;
• urinary smear microscopy screening;
• visualization of the pathology of the endocrine system;
• Ultrasound of cervical vessels and extremities, etc.

The choice of studies used will depend on the first results of mandatory diagnostics when the underlying cause of the disease is identified.

Methods of treatment

When a diagnosis of hypertension is suspected chronic disease, self-treatment is absolutely impossible. In order to correctly determine the nature of the disease and develop a treatment strategy, taking into account the current state of the patient, it is necessary to undergo a full examination by specialists. The thoughtless use of medicines can be fatal or lead to disability.

Should start immediately complex treatment after the diagnosis is made.

Complex therapy is represented by several drugs and compliance with the doctor's recommendations.

Drug therapy

When establishing the diagnosis of chronic arterial hypertension, treatment begins with taking medications in the complex:

1. Diuretic drugs. Diuretics prevent the accumulation of fluid and increase the density of the blood, and also contribute to the removal of salts.
2. calcium channel blockers. Designed to block the influx of calcium. Alpha-, beta blockers contribute to the control of the heart rhythm, lowering the function of contraction of the heart muscle.
3. ACE inhibitors. Drugs are prescribed to relax smooth muscles, preventing the release of calcium.
4. Angiotensin blockers that inhibit the synthesis of the hormone angiotensin, which causes vasoconstriction.

Only complex therapy allows achieving stable positive dynamics.

Non-drug treatment

Equally important is compliance with the doctor's recommendations regarding the lifestyle and diet of the patient. Medications can temporarily reduce pressure, and maintaining an appropriate lifestyle allows you to achieve a confident result, preventing the further development of the disease and the increase in symptoms.

The key to the success of treatment, first of all, is the observance of certain nutritional rules:

• salt intake is limited (up to 5 grams per day), animal fat;
• exclusion of smoked and fried foods;
• refusal or reduction in the amount of tea and coffee consumed;
• exclusion of alcoholic beverages;
• foods with a high content of potassium and calcium are introduced into the diet;
• avoidance of overeating.

These measures will eliminate excess weight, provoking disease and an increase in blood pressure. It is important to immediately stop smoking if you have an addiction and review your diet.

• introduce nuts, garlic, cabbage, spinach, legumes, beets, dried fruits (dried apricots, raisins, figs), rose hips, black currants into the diet;
• include regular sports activities (skiing, running, swimming) in the daily routine;
• lead an active lifestyle, walk;
• give up bad habits;
• take a contrast shower, water procedures;
• take courses of massage, relaxation;
• minimize stress on the body.

High blood pressure during pregnancy

When high blood pressure is detected during pregnancy, early dates or before it, doctors diagnose the chronic form of the disease, which occurs among pregnant women in 5% of cases.

If the pressure value is 140/90 and higher, a special set of measures is prescribed to stabilize the woman's performance. In especially severe forms, the indicators are above 180/110 mm Hg. Measurement of pressure in pregnant women can be carried out up to several times a day, because values ​​\u200b\u200bare possible to change during the day.

The diagnosis of "gestational hypertension" is made in the presence of high pressure in the second half of pregnancy and in the last stages. The observing gynecologist must distinguish between the nature of hypertension, prescribing the appropriate course, depending on the cause that caused high blood pressure. One of the manifestations of gestational hypertension is the presence of protein in the urine, indicating an increase in the risk of preeclampsia.

The danger of chronic hypertension in pregnant women

Especially dangerous when high pressure in a pregnant woman, the development of preeclampsia, which develops in almost half of the cases in pregnant women suffering from chronic hypertension in severe form.

The clinical picture of high blood pressure in pregnant women shows a decrease in blood flow through the placenta, causing a lack of oxygen and nutrients to the baby. In this case, doctors testify to a high risk of intrauterine growth retardation, placental abruption and premature birth.

With a mild form of manifestations of the disease, the risks of complications during pregnancy are within the normal range. This means the absence of increasing symptoms of the disease, similar to the conditions of a pregnant woman with normal pressure indicators, if no other disturbing symptoms are observed.

A more severe form of hypertension increases the risk of preeclampsia, especially in situations of high pressure over a long period and the presence of pathologies in the cardiovascular, renal system, or damage to other internal organs. One of alarms is the presence of a pregnant woman with diabetes mellitus, pyelonephritis or systemic lupus erythematosus. If there is a history of these types of diseases, you should tell the doctor about them at the first visit to the doctor when registering in a consultation.

Medical supervision during pregnancy

When addressing the patient chronic hypertension to the antenatal clinic in the early stages, the doctor will send for the study of urine and blood. In order to control the situation of the work of all internal organs, various types of instrumental diagnostics and clinical examinations can be prescribed:

• regular electrocardiogram;
• observation by an ophthalmologist;
• urinalysis according to the Zimnitsky method (daily analysis);
• other types of research depending on the symptoms.

A complete examination of a pregnant woman will reduce the various risks that appear during pregnancy in a patient with hypertension. In a severe form of the disease, it will be necessary to carefully monitor the pressure indicators throughout the pregnancy, strictly taking the drugs as directed. When writing a prescription and determining the treatment regimen, the doctor will proceed from the need to use a drug that is safe for the future baby. It is unacceptable to refuse medication during pregnancy in patients with severe hypertension, as this can lead to death. If the symptoms are mild, the doctor, based on examinations and tests, will decide to reduce or completely refuse medications, assessing the benefits to the health of the mother and the threat to life for the child and the pregnant woman.

If a patient with a mild form of the disease did not take any medications before pregnancy, the doctor may refuse to prescribe drugs. The reason lies in the generally accepted dynamics of the decrease in the rate of normal pressure in pregnant women in the first two trimesters. By the middle of the term, the pressure in most cases returns to its usual values. Taking medication to lower blood pressure can lead to a significant decrease in the indicator, while reducing blood flow through the placenta.

In the presence of high blood pressure in a pregnant woman, control in a medical institution becomes more frequent, additional examination options are prescribed (in addition to planned ultrasounds, the level of amniotic fluid, growth in fetal size, dopplerometry, various types of testing of the unborn child will be monitored). With a significant jump in pressure, the doctor decides on the hospitalization of the pregnant woman until the indicators stabilize. With the development of preeclampsia, the pregnant woman is in the hospital until the moment of delivery due to the particularly high risk of preterm birth.

All about the drug Perineva and its analogues

1. Regulation of blood pressure in the body
2. Perineva: how it works
3. How to use Perineva
4. When to start using Perineva
5. Reception regimen and principles of dose selection
6. special instructions
7. Overdose and side effects
8. Perineva's analogs
9. Reviews
10. conclusions

Perineva is a drug intended for the treatment of high blood pressure. Active substance Perineva - perindopril - belongs to the class of angiotensin-converting enzyme (ACE) inhibitors. The drug is produced by the Slovenian company KRKKA, which has a production branch in Russia.

Regulation of blood pressure in the body

To understand exactly how the remedy works, you need to know how blood pressure is regulated in the body. Regulation mechanisms are systemic and local. Local ones act at the level of the vascular wall and "correct" the result of the work of systemic mechanisms, based on the momentary needs of a particular organ.

Systemic mechanisms regulate blood pressure at the level of the body as a whole. According to the mechanism of action, they are divided into nervous and humoral. As the name implies, nervous mechanisms carry out regulation with the help of peripheral nervous system. Humoral mechanisms regulate systemic blood flow with the help of active substances dissolved in the blood.

One of the main mechanisms that controls systemic blood flow and, as a result, regulates blood pressure is the Renin-Angiotensin-Aldosterone system.

Renin is a hormone-like substance that is produced in the cells of the arterioles of the vascular glomeruli of the kidneys. It is also synthesized by the endothelium - the inner lining of the vessels of the brain, myocardium, glomerular zone of the adrenal cortex. Renin production is regulated by:

• The pressure in the blood-bearing vessel, namely, the degree of its stretching;
• The content of sodium in the distal tubules of the kidneys - the more it is, the more active is the secretion of renin;
• Sympathetic nervous system;
• By the principle of negative feedback, reacting to the content of angiotensin and aldosterone in the blood.

Renin transforms the angiotensinogen protein synthesized by the liver into the inactive hormone angiotensinogen I. With the blood flow, it enters the lungs, where it is converted into active angiotensin II under the action of angiotensin-converting enzyme (ACE).

Functions of angiotensin II:

• Narrows arteries, including coronary;
• Causes myocardial hypertrophy;
• Stimulates the release of vasopressin (aka antidiuretic hormone) in the pituitary gland, which retains water in the body, reducing its excretion by the kidneys;
• Stimulates the production of aldosterone in the adrenal glands

Perineva: how it works

Perineva blocks ACE, thus reducing the amount of angiotensin II in the body and eliminating its vasoconstrictive effects. In parallel, the secretion of aldosterone decreases, the retention of sodium and fluid in the body decreases. This reduces the volume of circulating blood and, as a result, reduces the pressure in the arterial system.

In general, the effects of the drug can be divided into the following groups:

Changes in the cardiovascular system:

Effects from the kidneys:

• Normalization of intraglomerular hemodynamics;
• Reducing proteinuria.

From the endocrine system:

• Reducing tissue resistance to insulin (important for patients with metabolic syndrome and type 2 diabetes);
• prevention of angiopathy and nephropathy caused by diabetes.

From other metabolic processes:

• Increased excretion of uric acid by the kidneys (important for patients with gout);
• Anti-atherosclerotic action: reduces the permeability of the cells of the inner wall (endothelium) of blood vessels and reduces the amount of lipoproteins in them.

With prolonged regular use, Perineva exhibits the so-called chronic antihypertensive effect. The reproduction and growth of smooth muscle cells in the middle wall of the artery decreases, which increases their lumen and restores elasticity.

How to use Perineva

• arterial hypertension,
• For cardioprotection in chronic heart failure,
• For cardioprotection after myocardial infarction or surgery coronary arteries subject to the stability of the ischemic process,
• To prevent recurrence of stroke in patients who once had it.

When to start using Perineva

The main indication for this is arterial hypertension. It is understood as an increase in systolic, “upper” blood pressure > 140 mm Hg. st and / or diastolic, “lower” blood pressure> 90 mm. rt. Art. An increase in pressure can be secondary, caused by diseases of other organs (glomerulonephritis, adrenal tumors, etc.) and primary, when it is impossible to identify and eliminate the cause of the disease.

Primary (essential) hypertension accounts for 90% of all cases of high blood pressure and is referred to as hypertension. The Ministry of Health of the Russian Federation in clinical guidelines of 2013 proposes the following criteria for its diagnosis:

Reception regimen and principles of dose selection

Recommended targets for blood pressure are less than 140/90 (for patients with diabetes mellitus - less than 140/85). The previously used concept of “working pressure” was recognized as incorrect - in order to prevent complications and reduce the likelihood of cardiovascular death, it is necessary to achieve target indicators. If the pressure is excessively high and its abrupt normalization is poorly tolerated, the correction is carried out in several stages.

In the first 2-4 weeks, blood pressure drops by 10-15% of the initial level, then the patient is given a month to get used to such pressure values. Further, the rate of decline is selected individually. The lower limit of the decrease in SBP is 115-110 mm Hg, DBP is 75-70 mm Hg, at excessively low levels, the risk of myocardial infarction and stroke again increases.

The medicine is taken once a day, in the morning. The initial dosage is 4 mg, for pensioners - 2 mg, gradually increasing to 4 mg. Patients taking diuretics should stop using them 2-3 days before the start of the course of Perineva, or start treatment with a dosage of 2 mg, also gradually increasing to 4 mg. According to the same principle, doses are selected for patients suffering from chronic heart failure.

After a month of regular intake, the effectiveness of the drug is evaluated. If the target blood pressure is not achieved, it is necessary to switch to a dosage of 8 mg.

For patients with stable coronary artery disease, Perineva is prescribed at a starting dosage of 4 mg, after 2 weeks they switch to 8 mg.

Contraindications:

special instructions

Perineva can provoke an excessive decrease in blood pressure when:

• cerebrovascular pathologies,
• Simultaneous use of diuretics,
• Loss of electrolytes: after a salt-free diet, vomiting or diarrhea,
• After hemodialysis,
• Stenosis of the mitral or aortic valves - since cardiac output in these conditions cannot increase, it is not able to compensate for the decrease in peripheral vascular resistance,
• renovascular hypertension,
• Chronic cardiovascular insufficiency in the stage of decompensation.

May exacerbate renal failure in patients with bilateral renal artery stenosis or stenosis of the artery to a single kidney.

Perinev should be used with extreme caution in women of childbearing age. Planned pregnancy is an indication for changing the antihypertensive drug.

Overdose and side effects

In case of an overdose, blood pressure drops excessively, up to shock, kidney failure develops, respiratory intensity (hypoventilation) decreases, heart rate can change both towards tachycardia and bradycardia, dizziness, anxiety, and coughing are possible.

In case of an overdose, it is necessary to lay the patient down, raising his legs, replenish the bcc, by intravenous administration of solutions. Angiotensin II is also administered intravenously, in its absence - catecholamines.

Side effects:

Perineva's analogs

To date, more than 19 drugs based on perindopril have been registered in the Russian Federation. Here are some of them:

• Prestarium. The drug, manufactured by the French company Servier, was the first drug based on perindopril that appeared at the disposal of doctors. It was on this drug that all studies on the effectiveness of perindopril, a decrease in cardiovascular risk (a decrease of 20%), and a positive effect on the condition of the walls of blood vessels were carried out. The cost is from 433 rubles.
• Perindopril-Richter. Production of the Hungarian company "Gedeon-Richter". Price from 245 rubles.
• Parnavel. Production of the Russian company Ozon. Price from 308 rubles.

When choosing from the possible options the best in terms of price-quality ratio, you need to remember that today, of all manufacturers of generic drugs, only KRKKA has proved the bioequivalence (correspondence to the original medicine) of its product.

The cost of Perineva in pharmacies is from 244 rubles.

Ko-Perineva

Monotherapy with perindopril (Perineva) allows you to achieve target blood pressure values ​​in patients with stages 1-2 hypertension in 50% of cases. In addition, often the therapy of arterial hypertension should immediately begin with a combination of two active substances.

The combination of perindopril and indapamide (thiazide diuretic) has proven to be one of the most effective. For the convenience of patients, this combination is available as a single tablet.

Co-perinev is produced in 3 dosages:

1. Perindopril 2 mg + indapamide 0.625 mg;
2. Perindopril 4 mg + indapamide 1.25 mg;
3. Perindopril 8 mg + indapamide 2.5 mg.

The cost in pharmacies - from 269 rubles.

Contraindications

In addition to those already indicated for perindopril, for Ko-perineva:

• Azotemia, anuria;
• Liver failure.

Side effects

In addition to the adverse events characteristic of perindopril, Ko-perinev can cause:

• Hemolytic anemia, hemorrhagic vasculitis - extremely rare;
• Photosensitivity, erythema multiforme - very rare;

In acute or gradually progressive impairment of kidney function, the regulation of blood pressure is disturbed. Hypertension is most often noted, it requires a special selection of medications for control. Low blood pressure occurs in patients on program hemodialysis or is a response to massive antihypertensive therapy.

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What is the pressure in kidney failure

The filtration capacity of the kidneys depends on the value of blood pressure, its level determines the life expectancy of patients with renal failure. Urine excretion stops when the systolic rate is below 80 mm Hg. Art., and contributes to the destruction of renal tissue.

high

Hypertension is the most common form of disorders in chronic kidney failure. It usually develops even before renal dysfunction, and with its onset, it is detected in almost 90% of patients. High blood pressure is accompanied by glomerulonephritis, pyelonephritis, amyloidosis and polycystic kidney disease, it is often found in diabetic nephropathy.

Hypertension itself leads to kidney damage. It has been proven that even a moderate increase in performance over several years leads to the destruction of nephrons. With ineffective treatment, this leads to severe and even end-stage renal failure.

Arterial hypertension is regarded as an unfavorable factor affecting not only the rapid progression of impaired blood purification by the kidneys, but also reduces the life expectancy of patients.

Low

Hypotonic reactions in acute renal failure may be associated with a drop in cardiac output during shock, a sharp decrease in circulating blood volume during dehydration. They often occur with an overdose. But the most common cause of low blood pressure is hemodialysis. appears in patients with:

• high speed or large volume filtration;
• with heart failure;
• long-term dialysis (more than 5 years);
• excessive activation of the parasympathetic system (reflex reaction to blood cleansing).

The danger of hypotension is to reduce the nutrition of the kidneys, heart and brain. It can be deadly, especially for elderly patients due to acute disorders circulation.

Treatment of hemodialysis hypotension requires the correct selection of the regimen of the procedure, with a sharp decrease, Dobutamine can be introduced.

Normal (target)

Even with timely detection of arterial hypertension and regular intake of antihypertensive drugs, it is possible to achieve protection of kidney tissue in only 10-15% of patients. The lowest therapy success rates were observed for obesity, diet neglect and smoking. The level of blood pressure that should be aimed at to slow the progression of kidney failure (target) depends on the degree of protein loss in the urine.

The very appearance of proteinuria is a risk factor for high blood pressure. Even with normal after the detection of protein in the urine, hypertension soon develops. In the absence of albuminuria, the generally accepted level of 140/90 mm Hg is considered normal. Art., if it is below 1 g per day, then 130/85 units, and at higher values ​​- 125/80. At the same time, the deterioration of blood flow in the kidneys begins to develop at systolic pressure below 115 mm Hg. Art.

For older people with widespread, individual target values ​​are set, taking into account possible complications. A sharp decrease or fluctuation in hemodynamic parameters often leads to a stroke and.

Watch the video about the causes of high blood pressure of renal origin:

Relationship between chronic renal failure and hypertension

The development of arterial hypertension in violation of the kidneys is associated with several reasons:

• activation of the formation of renin and the launch of a chain of its transformations into angiotensin 2;
• increased levels of aldosterone;
• increased release of adrenaline and increased tone of the sympathetic nervous system;
• water and sodium retention;
• dysfunction of baroreceptors (react to pressure) and chemoreceptors (perceive changes in blood composition);
• acceleration of the formation of vasoconstrictor substances;
• anemia, drugs for its treatment (erythropoietin);
• volume overload when making for dialysis.

It should be borne in mind that a third of patients had arterial hypertension even before the onset of chronic renal failure due to kidney disease or hypertension complicated by nephropathy.

Choosing a pressure medication for kidney failure

In patients with impaired renal function, drugs to treat hypertension should address the underlying causes of hypertension. It is important that their use does not reduce renal blood flow and urine filtration. Essential requirements also include a minimum impact on metabolic processes and minor side effects.

Diuretic tablets

Loop diuretics are used to remove excess sodium and water. Most often it is Lasix or Uregit. They increase the filtration capacity of the kidneys and excrete potassium, which is greatly increased in renal failure. For the same reason () do not recommend Veroshpiron, Triampur and Moduretik. Thiazide drugs (Hypothiazid, Oxodoline) are contraindicated in patients with reduced kidney function.

One of the most prescribed groups for lowering blood pressure. They have such advantages:

• improve blood circulation in the kidneys;
• do not retain sodium;
• protect kidney tissue from destruction;
• normalize not only systemic, but also intraglomerular pressure;
• reduce protein loss;
• slow down the progression of renal failure;
• do not change lipid metabolism.

For treatment use: Corinfar, Lomir, Nicardipine, Diacordin retard.

ACE inhibitors

They have advantages in the initial stages of renal failure, but are potentially dangerous during the use of diuretics or hemodialysis. They can cause an increase in potassium in the blood, a deterioration in performance, an increase in protein loss in the urine, and severe allergic reactions. Usually they are not used for monotherapy, but are included in complex treatment in small doses.

Angiotensin II receptor blockers have similar pharmacological effects, they prevent the vasoconstrictor action of this compound, but do not impair renal function. To the most effective drugs include: Lorista, Vazar, Aprovel.

Adrenoblocker tablets

At severe course hypertension against the background of a high level of renin in the blood, large doses of adrenergic blockers are recommended.

Both beta-blockers (Concor, Lokren) and combined alpha and beta antiadrenergic drugs (Carvedilol, Lacardia) can be used. They are used with caution in the development of heart failure, as they can reduce cardiac output.

If necessary, the appointment is combined with cardiac glycosides under the control of potassium levels in the blood.

Combination Therapy

A single drug rarely achieves a stable reduction in blood pressure in patients with kidney disease. Increasing the dose in renal failure can be dangerous. Therefore, the best option is a combination of drugs. Combinations that work well:

• Corinfar + Dopegit + Sotalol;
• Tritace + Lasix + Coriol;
• Diacordin + Concor + Kamiren.

Non-pharmacological treatment of hypertension in renal failure

To effectively control blood pressure and kidney function, patients require special nutrition. The basic principles of compiling a diet for renal failure:

• reduction in protein intake to 0.7 g per 1 kg of body weight per initial stage, then it is limited to 20 g per day;
• all the necessary protein should come from lean meat, cottage cheese, eggs and fish;
• due to the high tendency to atherosclerosis, animal fat is replaced with vegetable fat, seafood is recommended;
• to calculate the drinking ration, daily diuresis is measured and 500 ml is added to it;
• in the absence of edema, table salt in the amount of 3-5 g is given to the hands for salting, and prepared without it, if there are edema and persistent hypertension, then reduce to 1-2 g per day.

If high blood pressure remains on the background of the diet and the use of combined antihypertensive therapy, sodium is removed by blood filtration (hemofiltration, dialysis). Patients who are scheduled for a kidney transplant and whose blood pressure remains critically high have two kidneys removed and undergo regular hemodialysis sessions prior to transplantation.

The kidneys are the organ that regulates blood pressure. In renal failure, arterial hypertension most often occurs. If it cannot be corrected, then the signs of impaired urine filtration progress, and the life expectancy of patients is reduced. H

low pressure is less common, for its correction it is necessary to eliminate the cause (shock, dehydration, overdose of antihypertensive drugs). Hypertension therapy includes different groups of drugs, their combinations, diet food and non-drug methods blood filtration.

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Atherosclerosis of the renal arteries develops due to age, bad habits, overweight. Initially, the symptoms are hidden, if they appear, then the disease progresses greatly. In this case, it is necessary drug treatment or operation.

Life-threatening renal artery thrombosis is difficult to treat. The reasons for its appearance are valve defects, a blow to the stomach, the installation of a stent, and others. Symptoms are similar to acute renal colic.

Kidney disease can cause secondary hypertension, which is called hypertension in renal failure. The peculiarity of this condition is that, together with nephropathy, the patient has high values ​​of systolic and diastolic pressure. Treatment of the disease is long. Arterial hypertension of any origin is a common cardiovascular disease and occupies 94-95% of them. The share of secondary hypertension accounts for 4-5%. Among secondary hypertension, renovascular hypertension is the most common and accounts for 3-4% of all cases.

Where is the connection?

The occurrence of arterial hypertension in chronic renal failure (chronic renal failure) is due to changes in the normal functioning of the organs of the urinary system, in violation of the blood filtration mechanism. In this case, excess fluid and toxic substances (sodium salts and protein breakdown products) cease to be excreted from the body. Excess water accumulated in the extracellular space provokes the appearance of edema of the internal organs, hands, feet, face.

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From a large amount of fluid, the renal receptors are irritated, the production of the enzyme renin, which breaks down proteins, increases. In this case, there is no increase in pressure, but interacting with other blood proteins, renin promotes the formation of angiotensin, which promotes the formation of aldosterone, which retains sodium. As a result, there is an increase in the tone of the renal arteries and the formation of cholesterol plaques, which narrow the cross section of blood vessels, is accelerated.

In parallel, the content of derivatives of polyunsaturated fatty acids and bradykinin, which reduce the elasticity of blood vessels, decreases in the kidneys. As a result, high blood pressure is persistent. Hemodynamic disorder leads to cardiomyopathy (left ventricular hypertrophy) or other pathological conditions of the cardiovascular system.

Reasons for the development of renal failure with blood pressure

The most common cause of the development of the disease is pyelonephritis.

The functioning of the renal arteries is impaired in nephropathology. A common cause of nephrogenic arterial hypertension is arterial stenosis. Narrowing of the section of the renal arteries due to thickening of the muscular walls is observed in young women. In older patients, the narrowing appears due to atherosclerotic plaques that impede the free flow of blood.

Factors that provoke high blood pressure in nephropathies can be divided into 3 groups - negative changes in the parenchyma (kidney membrane), damage to blood vessels and combined pathologies. The causes of diffuse pathologies of the parenchyma are:

• glomerulonephritis;
• lupus erythematosus;
• diabetes;
• urolithic pathologies;
• congenital and acquired anomalies of the kidneys;
• tuberculosis.

Among the causes of vasorenal hypertension associated with the state of the blood vessels, note:

• atherosclerotic manifestations in the older age group;
• anomalies in the formation of blood vessels;
• tumors;
• cysts;
• hematomas.

Nephrogenic hypertension is very resistant to medications that lower blood pressure.

A characteristic feature of nephrogenic hypertension is the ineffectiveness of drugs that reduce blood pressure, even in the case of high values. Provoking factors can have a negative impact both singly and in any combination of damage to the parenchyma and blood vessels. In this situation, it is very important to identify existing problems in a timely manner. For patients with a diagnosis of renal insufficiency, dispensary observation of a doctor is necessary. A competent specialist will be able to choose complex therapy for the underlying pathology and medications to lower blood pressure.

Course of the disease

Doctors distinguish two types of the course of the disease: benign and malignant. Benign type of renal hypertension develops slowly, and malignant quickly. The main symptoms of various types of renal hypertension are shown in the table:

The disease can cause poor blood flow in the brain.

Arterial hypertension in pathological conditions of the kidneys provokes the following problems:

• violation of the blood flow of the brain;
• changes in blood biochemical parameters (low hemoglobin and red blood cells, platelets, leukocytosis and increased ESR);
• hemorrhage in the eye;
• violation of lipid metabolism;
• damage to the vascular endothelium.