CKD 2021 da qon bosimi maqsadlari: hech qachon tugamaydigan ko'rsatmalarning buzilishi

ANTRACT

2021 yilda ikkita yangilangan klinik ko'rsatmalar nashr etildiqon bosimi bo'yicha ko'rsatmalar(BP) surunkali buyrak kasalligi (CKD) bo'lgan odamlar uchun maqsadlar.Buyrak kasalligi: Global natijalarni yaxshilash(KDIGO) o'zining 2012 yildagi KKDda qon bosimini boshqarish bo'yicha Klinik amaliyot qo'llanmasini yangiladi.Turli xil sistolik qon bosimiCKD uchun (SBP) va diastolik qon bosimi (DBP) maqsadlari (<130/80 and <140/90 mmHg, respectively, for people with urinary albumin: creatinine ratio >30 mg/g yoki patologik albuminuriyasiz) bitta raqam bilan almashtirildi: SBP maqsadi<120 mmHg is suggested when tolerated. This represents a major decrease in the SBP target and the abandonment of DBP targets. The European Society of Cardiology (ESC) also published a 2021 Clinical Guideline on Cardiovascular Disease Prevention in Clinical Practice that updates a prior 2016 guideline on prevention and the 2018 ESC/European Society of Hypertension Clinical Practice Guidelines for the Management of Arterial Hypertension. The 2021 ESC guideline was endorsed by 12 European scientific societies. The recommended office BP targets for people with CKD are <140–130 mmHg SBP (lower SBP is acceptable if tolerated) and <80 mmHg DBP. The question is: What should the practicing physician do now: treat hypertension in people with CKD to an SBP target of <120 mmHg or to a target of <140–130 mmHg? Major guideline bodies are aware of the activities of other major players. There is an urgent need for guideline bodies to establish communication channels, search for consensus on major issues that impact the health of hundreds of millions of people worldwide, and end individualism in guidelines generation. 

Kalit so'zlar: qon bosimi maqsadlari,surunkali buyrak kasalligi, Evropa Kardiologiya Jamiyati, ko'rsatmalar, gipertenziya

CISTANCHE QANCHA VA QANCHA KETADI?

Dunyo bo'ylab 850 millionga yaqin odam borsurunkali buyrak kasalligi (CKD) and >Ularning 80% i gipertoniya bilan kasallangan [1]. 2000 yilda dunyo bo'ylab tarqalganligi 972 millionni tashkil etgan gipertoniya bilan og'rigan odamlarning katta qismida bir vaqtning o'zida KKH bo'lishi mumkin. CKDdan o'lim tez sur'atlar bilan o'sib bormoqda va 2040 yilga borib o'limning beshinchi asosiy sababi va umr ko'rish davomiyligi uzoq bo'lgan ba'zi mamlakatlarda asr oxirigacha ikkinchi o'lim sababi bo'lishi kutilmoqda [2, 3]. Ushbu prognozlarning amalga oshishiga yo'l qo'ymaslik uchun chora ko'rish sog'liqni saqlashning ustuvor yo'nalishidir [4]. Yurak-qon tomir kasalliklaridan o'lim KKHda o'limga olib keladigan eng katta omillardan biridir [5]. Shunday qilib, CKDda qon bosimini (BP) nazorat qilish bo'yicha maqsadlarni belgilash butun dunyo bo'ylab yuzlab million odamlar uchun erta o'lim xavfiga ta'sir qiladi va keyingi o'n yilliklarda o'limning asosiy sabablariga ta'sir qilishi mumkin. Biroq, asosiy yo'riqnomalar CKD uchun BP maqsadlari bo'yicha kelisha olmaydi [6, 7]. Shunday qilib, 2019 yilda CKJ sahifalarida xaotik deb atalgan vaziyat yangi o'n yillikda ham saqlanib qoladi [8]. Turli xil BP maqsadlarini taklif qilish/tavsiya qilish uchun turli dalillarni o'rganib, vaqtning turli nuqtalarida ishlab chiqarilgan ko'rsatmalar uchun asos bo'lishi mumkin bo'lsa-da, juda xilma-xil tavsiyalarni berish uchun bir xil dalillardan foydalangan holda 5 oy davomida nashr etilgan ikkita ko'rsatmalar uchun juda oz asos mavjud.

1-rasm:CKDda turli xil terapevtik maqsadlar bemorlareski (2012–18) yoki yangiroq (2021 yoki yaqinda yangilanmagan) ko'rsatmalar tomonidan tavsiya etilgan yoki tavsiya etilganidek. (A) Eski ko'rsatmalar: Surunkali buyrak kasalligida qon bosimini boshqarish bo'yicha 2012 yil KDIGO Klinik amaliy qo'llanmasi, 2017 yil ACC/AHA yo'riqnomasi va 2018 yil ESC/ESH yo'riqnomasi. (B) 2021 KDIGO va ESC yo'riqnomalari va 2017 ACC/AHA yo'riqnomalari hali yangilanmagan va shuning uchun joriy bo'lib qoladi. Yodda tuting, terapevtik maqsadlar ko‘rsatmalar o‘rtasida, hatto 2021-yilda chop etilgan ikkita yo‘riqnoma o‘rtasida ham farqlanadi. Ustunlarning ko‘k rangi maqsadli qon bosimini bildiradi. Qizil rangdagi individual raqamli qiymatlar bir xil kontseptsiya uchun uchta yo'riqnomaning eng yuqori qiymatlarini (sistolik yoki diastolik qon bosimini), to'q sariq rangda - oraliq qiymatlarni va yashil rangda - bir xil kontseptsiya uchun uchta yo'riqnomaning eng past qiymatlarini ifodalaydi. Panel (A) [8] dan moslashtirilgan. KDIGO maqsadlari dializsiz, transplantatsiya qilinmagan CKD uchun taklif etiladi. Buyrak transplantatsiyasini qabul qiluvchilar uchun KDIGO 2021 BP maqsadlari faqat kamtarona o'zgartirildi<130 mmHg SBP and <80 mmHg DBP. KDIGO 2021 provides no recommendations for patients on dialysis. ESC guidelines do not provide specific advice for kidney transplant recipients or patients on dialysis.

2021-yilda ikkita asosiy yo‘riqnoma yangilandi (mos ravishda 2012 va 2018-yillardan boshlab) KKD bilan og‘rigan odamlar uchun BP maqsadlari bo‘yicha tavsiyalar: Buyrak kasalligi: Surunkali buyrak kasalligida qon bosimini boshqarish bo‘yicha 2021 yilgi global natijalarni yaxshilash (KDIGO) Klinik amaliyot qo‘llanmasi [6] va Evropa Kardiologiya Jamiyati (ESC) 2021 Klinik amaliyotda yurak-qon tomir kasalliklarining oldini olish bo'yicha klinik qo'llanma [7]. Ikkala yangi yo'riqnoma ham qabul qilish va amalga oshirishga yordam beradigan soddalashtirilgan xabarni taqdim etadi. Afsuski, tavsiya etilgan/tavsiya etilgan sistolik qon bosimi (SBP) 20 mmHg gacha o'chirilgan. Bu chalkashliklarni keltirib chiqaradi va amalga oshirishga to'sqinlik qiladi. BP ning CKD bilan kasallangan yuz millionlab odamlarga mo'ljallangan maqsadlari kabi asosiy masalalar bo'yicha konsensusga erishish uchun shoshilinch ehtiyoj bor.

KDIGO 2012DAN KDIGO 2021 KLINIK AMALIYOT QOʻYILMASINING KBHDA QON BOSIMINI BOSHQARISH BOʻYICHA 2012 yilgi KDIGO yoʻriqnomasida qandli diabet yoki patologik siydik albuminuriyasining mavjudligi yoki yoʻqligiga asoslangan nisbatan murakkab qon bosimi koʻrsatkichlari mavjud edi. > 30 mg/g] diyalizda bo'lmagan CKD bo'lgan kattalar uchun (1A-rasm) [9]: • Tavsiya: diabetga chalingan bo'lmagan, UACR<30 mg/g; office SBP target ≤140 mmHg, DBP ≤90 mmHg (1B). • Suggestion: non-diabetic, UACR 30–300 mg/g; office SBP targets ≤130 mmHg, DBP ≤80 mmHg (2D for UACR 30–300 and 2C for UACR > 300 mg/g in non-diabetics, 2D for diabetics).

Ya'ni, KDIGO 2012 uchun diabetik bo'lmagan, normoalbuminurik CKD bo'lgan bemorlar uchun 140/90 mmHg BP etarli edi. Transplantatsiya qilingan bemorlar patologik albuminuriya bilan og'rigan bemorlar bilan bir xil maqsadga ega bo'lgan holda, dializdagi bemorlar uchun tavsiyalar yo'q edi [9]. 2021-yilgi KDIGO yoʻriqnomasida oddiyroq xabar bor: “Biz yuqori qon bosimi va CKD boʻlgan kattalarni maqsadli SBP bilan davolashni taklif qilamiz.<120 mmHg, when tolerated, using standardized office BP measurement (2B)' (Fig. 1B) [6]. Additionally, it guides how to measure office BP (Table 1). The suggestion is based on the Systolic Blood Pressure Intervention Trial (SPRINT) [10]. SPRINT randomly assigned participants to an SBP target of <120 mmHg or <140 mmHg. Patients with an estimated glomerular filtration rate <20 mL/min/1.73 m2, 24-h urine protein excretion >1 g, diyaliz yoki buyrak transplantatsiyasi qabul qiluvchilar chiqarib tashlandi. CKD bilan og'rigan bemorlarning kichik guruhida 1 yil davomida erishilgan qon bosimi 123,3 ± 0,4/66,9 ± 0,3 mmHg ni, 136,9 ± 0,4/73,8 ± {{ 16}},3 mmHg [11]. CKD bilan og'rigan bemorlarda o'rtacha 3,3 yillik kuzatuvdan so'ng, yurak-qon tomir tizimining birlamchi kompozitsion natijasi uchun xavf nisbati 0,81 [95% ishonch oralig'i (CI) 0,63-1 edi. {{30}}5] va barcha sabablarga ko'ra o'lim uchun bu 0,72 (95% CI 0,53-0,99), ammo SBP nishoni bo'lgan bemorlar<120 mmHg lost GFR at a 47% faster rate (–0.47 versus –0.32 mL/min/1.73 m2/year; P < 0.03). SPRINT measured BP in a standardized manner (Table 1). However, in SPRINT, there were four different groups of patients about the presence of the doctor or study personnel during rest or the actual BP readings (attended versus unattended BP) [12], a factor that can directly influence the levels of measured BP [13]. These four groups displayed no homogeneity in the primary study outcome, a fact that makes the interpretation of the SPRINT results quite difficult.

Jadval 1. Ofis BP o'lchash uchun standartlashtirilgan shartlar

Jadval 1. Davomi

2-jadval. ESC 2021 SBP maqsadini tasdiqlovchi ilmiy jamiyatlar<140–130 mmHg for people with CKD

Buyrak transplantatsiyasini qabul qiluvchilar uchun BP maqsadlari faqat kamtarona o'zgartirildi<130 mmHg SBP and <80 mmHg DBP. Again, KDIGO 2021 provides no recommendations for patients on dialysis. From 2018 ESC/European Society of Hypertension (ESH) Clinical Practice Guidelines for the Management of Arterial Hypertension to 2021 ESC Clinical Guidelines on Cardiovascular Disease Prevention in clinical practice (endorsed by 12 European scientific societies, including the ESH) (Table 2). The 2018 ESC/ESH guidelines contained a complex set of suggestions to determine whether to start therapy for hypertension, based on age [13]. Thus patients with CKD >80 yoshda, SBP 160 mmHg dan yuqori yoki teng yoki DBP 90 mmHg dan katta yoki teng bo'lmaguncha, gipertenziya uchun farmakologik terapiyani boshlamaydi. Aksincha, yosh bemorlarda terapiyani boshlash chegarasi 140/90 mmHg edi. Biroq, terapiya boshlangandan so'ng, maqsad barcha yoshdagi kattalar KKH bemorlari uchun bir xil edi: 130-139 mmHg SBP va 70-79 mmHg DBP (1A-rasm). CKD maqsadi umumiy populyatsiyadagi yosh (18-65 yosh) odamlar yoki diabetga chalinganlar uchun ko'ra yuqoriroq bo'lib, ularda maqsad SBP 120-129 mmHg bo'lgan, bu bo'lmasligi kerakligi haqida eslatma bilan.<120 mmHg. This discrepancy in the target BP for patients with CKD versus those with diabetes or individuals from the general population was not supported by any kind of observational or clinical trial evidence. ESC 2021 decreases differential SBP thresholds at which to initiate therapy based on age but still recommends a higher SBP target (130–139 mmHg) in adults with CKD of any age (Fig. 1B) than in younger people in the general population or in diabetics (120–130 mmHg if <70 years of age and 130–139 mmHg for those ≥70 years of age) [7]. A more subtle change to the 2018 document deemed a lower SBP acceptable in CKD if tolerated. Additionally, the DBP target is universally <80 mmHg for all treated patients, independent of any associated comorbidity. The proposed BP assessment method is similar to that proposed by KDIGO 2021 (Table 1), ruling out that methodological differences explain the different BP targets. ESC 2021 does not provide the rationale for target BP values in people with CKD and does not mention the SPRINT subanalysis of participants with CKD or the 2021 KDIGO guideline on BP and CKD, although it does cite other KDIGO guidelines on lipids and diabetes, one of which was accessed in June 2021 [7]. However, it does explain changes from the prior 2016 ESC prevention and 2018 ESC/ESH hypertension guidelines in the cut-off for identifying who is 'older' (from 65 to 70 years for reasons of consistency with other parts of the current guidelines), in BP targets for the elderly (based on the SPRINT subanalysis of people ≥75 years of age and others) and the rationale for BP targets for people with lower extremity artery disease [13–15].