Suzanne Oparil：美国阿拉巴马大学伯明翰分校教授，JNC 8指南委员会主席，美国高血压协会（ASH）前任主席。

    <International Circulation>:  For people with chronic kidney disease(CKD)， what medical therapy is suitable for their hypertension?

　　《国际循环》：目前有哪些治疗方案适合合并慢性肾脏疾病(CKD)的高血压患者？
　　Dr Oparil: The medicines you give them are determined by the level of renal function. We use eGFR (estimated glomerular filtration rate) based on their age， gender and race as well as serum creatinine levels. There are different stages of chronic kidney disease. If you are in stage 3 with an eGFR <60ml/(min﹒1.73m2)， which is pretty common in the US population， these people would probably tolerate and benefit from a thiazide-like diuretic such as chlortalidone， which is more powerful than hydrochlorothiazide. Once you get into stage 4 (eGFR<30 ml/(min﹒1.73m2))， patients generally require a loop diuretic which may be in addition to a thiazide-like diuretic or on its own. If you use furosemide which is the most common loop diuretic used in the US， it needs a twice daily dose because it is very short-acting. If you get an eGFR<15 ml/(min﹒1.73m2)， the patient probably needs to be prepared for dialysis. Also， even with strong diuretics， chronic kidney disease tends to be associated with volume retention and the blood pressure tends to be a little bit harder to manage so three or four drugs are usually required. This might include a dihydropyridine calcium-channel blocker like amlodipine. And you would need an ACE-inhibitor or ARB. At one time there was enthusiasm for using both an ACE and an ARB but most people now only do that if the patient has proteinuria which is a separate pathology. Then you will need another drug， spironolactone， maybe a beta-blocker， maybe an alpha-blocker. So these patients get pretty difficult to manage.

　　慢性肾脏疾病（CKD）的高血压患者的治疗方案取决于他们肾功能的情况。在临床上我们用通过基于患者年龄、性别和种族以及血清肌酐水平计算而来的eGFR（估计的肾小球率过滤）来评价肾功能。慢性肾脏疾病有不同的分期。如果是CKD3期的患者，且其eGFR <60 ml﹒min^-1﹒(1.73 m²) ^-1，这种情况在美国人群中很常见，这些患者可能耐受噻嗪类利尿剂（如氯噻酮）并从中获益，这种利尿剂比双氢克尿噻利尿效果更好。一旦患者进入CKD4期（eGFR<30 ml﹒min^-1﹒[1.73m²] ^-1），他们就常常需要合用袢利尿剂与噻嗪类利尿剂或单独使用袢利尿剂。如果给你患者使用的是在美国最常使用的袢利尿剂速尿，那就需要每日2次给药，因为这种利尿剂的作用时间很短。如果患者的eGFR<15 ml﹒min^-1﹒(1.73m²) ^-1，他们就可能需要准备做血液透析治疗。同时需要注意的是，即使使用了很强的利尿剂，慢性肾脏病患者也常常会发生体液潴留，并且他们的血压也常常会更难控制，因此合并慢性肾脏病的高血压患者常常需要同时使用3~4种药物。