透析患者での血圧降下はやはり重要

腎疾患がある場合は降圧目標１３０／８０は既に多くのガイドラインで推奨されていますから周知の事実であり，表題のことが真実であっても自分の診療がこれまでと変わらないので，通常は読み飛ばす論文ですが，現実的には，透析歴の長い方は，なかなか血圧が下がらず，ついあきらめてしまいがちですので，逆に「そうでなければいいわけになるのに」というかすかな期待と共に読みました．

全文は読んでいませんが，下記のシステマティックレビュー・メタ分析から．

分析対象８論文，１６７９人４９５の心血管イベント
平均血圧降下度　収縮期　4.5 mmHg, 拡張期　2.3mmHg
心血管イベント　(RR 0·71, 95% CI 0·55—0·92; p=0·009)
全死亡　　　　　(RR 0·80, 0·66—0·96; p=0·014)
心血管関連死亡　(RR 0·71, 0·50—0·99; p=0·044)


目標血圧１３０／８０は難しいかもしれませんが，その患者さんのベースラインの血圧から４．５mmHg下げるだけで上記アウトカムが0.7-0.8まで下がるということで努力はやはりするべきと思われます．

Effect of lowering blood pressure on cardiovascular events and mortality in patients on dialysis: a systematic review and meta-analysis of randomised controlled trials　．　The Lancet, Volume 373, Issue 9668, Pages 1009 - 1015, 21 March 2009

Editors' note: The number of people receiving dialysis is high and increasing. Such patients are at higher risk of cardiovascular disease and death than the general population. The renal system is important in regulating blood pressure so patients needing dialysis present a target population for blood pressure control. The few studies looking at blood pressure in dialysis patients have come up with diverse results which has not made generalisation easy. This meta-analysis clearly shows that control of blood pressure in dialysis patients is effective in reducing cardiovascular disease and mortality and the authors suggest that a simple, cheap, and effective treatment of BP should be seriously considered for all dialysis patients.


Hiddo J Lambers Heerspink PharmD a b, Toshiharu Ninomiya MD a, Sophia Zoungas MD a d, Prof Dick de Zeeuw MD b, Prof Diederick E Grobbee MD a c, Meg J Jardine MD a, Martin Gallagher MD a, Matthew A Roberts MD e f, Prof Alan Cass MD a, Prof Bruce Neal MD a, Dr Vlado Perkovic MD a

Summary
Background
Patients undergoing dialysis have a substantially increased risk of cardiovascular mortality and morbidity. Although several trials have shown the cardiovascular benefits of lowering blood pressure in the general population, there is uncertainty about the efficacy and tolerability of reducing blood pressure in patients on dialysis. We did a systematic review and meta-analysis to assess the effect of blood pressure lowering in patients on dialysis.
Methods
We systematically searched Medline, Embase, and the Cochrane Library database for trials reported between 1950 and November, 2008, without language restriction. We extracted a standardised dataset from randomised controlled trials of blood pressure lowering in patients on dialysis that reported cardiovascular outcomes. Meta-analysis was done with a random effects model.
Findings
We identified eight relevant trials, which provided data for 1679 patients and 495 cardiovascular events. Weighted mean systolic blood pressure was 4·5 mm Hg lower and diastolic blood pressure 2·3 mm Hg lower in actively treated patients than in controls. Blood pressure lowering treatment was associated with lower risks of cardiovascular events (RR 0·71, 95% CI 0·55—0·92; p=0·009), all-cause mortality (RR 0·80, 0·66—0·96; p=0·014), and cardiovascular mortality (RR 0·71, 0·50—0·99; p=0·044) than control regimens. The effects seem to be consistent across a range of patient groups included in the studies.
Interpretation
Treatment with agents that lower blood pressure should routinely be considered for individuals undergoing dialysis to reduce the very high cardiovascular morbidity and mortality rate in this population.
Funding
National Health and Medical Research Council of Australia Program.