原发性肾病综合征动态血压监测对减轻肾损害的研究
摘要
研究背景原发性肾病综合征(primary nephrotic syndrome, PNS)是儿童最常见的肾实质性病变,疗程长、治疗复杂,存在一系列促进其不断发展的因素。高血压状态可能使PNS患者肾损害持续存在,加速肾功能恶化,是发展到终末期。肾病(end-stage renal disease, ESRD)的独立危险因素。成人研究表明肾脏病变进展与收缩压(systolic blood pressure, SBP)、平均动脉压(mean arterial pressure, MAP)等呈明显正相关。慢性肾脏病时肾小球滤过率(glomerular filtration rate, GFR)下降程度与血压特别是收缩压密切相关,有效控制血压是保护病人肾脏的重要方法。
PNS的高血压机制尚未完全明确,可能与多种因素有关,高血压对肾脏损伤的机制可能包括血流动力学因素、非血液动力学因素。可能与交感神经系统(sympathetic nervous system, SNS)和肾素-血管紧张素-醛固酮系统(renin-angiotensin-aldosterone system, RAAS)的亢进等有关。
已有的关于高血压与肾脏疾病关系研究的资料主要为成人高血压与慢性肾损害关系的研究以及Ⅱ型糖尿病慢性肾损害及血压变化的研究。儿童高血压对肾脏损害的影响可能类似于成人的表现,但必然有不同之处,目前儿童类似研究较少,因此慢性肾损害尤其是易复发而治疗困难的PNS儿童高血压与肾损害相互影响的研究急需开展。
动态血压监测刂(ambulatory Blood Pressure monitoring, ABPM)避免了人为误差,能较好反应血压水平和血压变化规律。ABPM显示的血压水平与靶器官损害的相关性优于随机血压(casual blood pressure, CBP), ABPM监测也能更好地评估血压控制水平。
血管紧张素转化酶抑制剂(angiotensin-converting enzyme inhibitor, ACEI)通过能够控制血压水平和降低尿蛋白排泄率等途径显示出对肾脏的保护作用,蒙诺(福辛普利)是具有肝肾双通道清除模式的ACEI,肾损害儿童通过肝脏代偿性排出增多,使药物总体清除保持相对稳定,避免了药物蓄积。ABPM能为PNS儿童应用蒙诺等ACEI降压药提供疗效依据。
目的研究PNS儿童ABP的变化及临床意义；探讨PNS儿童RAAS活性升高与ABP的关系以及与PNS发病机制的关系；探讨SNS活性升高与ABP的关系和与PNS发病机制的关系；探讨PNS儿童RAAS活性升高与SNS活性升高的关系；探讨ABPM评价蒙诺疗效的运用和依靠ABPM创建新的用药方法。
方法采用动态血压仪对PNS儿童进行动态血压监测并应用普通水银血压计进行随机血压测量；应用γ-放射免疫计数器检测血肾素(plasma renin, PRA)、血管紧张素Ⅱ(AngiotensinⅡ, AngⅡ)和醛固酮(aldosterone, ALD)水平,并与ABP变化作相关性分析；应用高效液相色谱电化学发光检测24小时尿SNS的去甲肾上腺素(noradrenaline, NA)、肾上腺素(adrenaline, A)、多巴胺(dopamine,DA)水平,并与ABP变化作相关性分析；蒙诺不同用药方法比较观察2w后ABPM的变化,分析蒙诺不同用药方法与ABP变化的关系。
结果
1.原发性肾病综合征儿童ABPM比CBP具有更高的阳性率,动态高血压101例(88.6%),发病率高。PNS儿童SBP升高更明显。轻重度隐匿性高血压45例(占全部PNS的39.5%),其中重度MHT18例(占全部PNS的15.8%)。非杓型血压发病率高,共80例(70.2%)。ABP均值和负荷的升高的PNS儿童出现明显的内生肌酐清除率减低和24小时尿蛋白、尿β2-微球蛋白(β2-microglobulin,02-MG)和尿N-乙酰葡糖胺酶(N-acetylglucosaminidase, NAG)增多。非杓型血压PNS儿童明显的内生肌酐清除率(creatinine clearance, Ccr)减低和24小时尿蛋白、尿β2-MG和尿NAG增多。
2.PNS组卧位血RAAS水平比正常对照组明显升高。AngⅡ水平与ABPM各个时段SBP、舒张压(diastolic blood pressure, DBP)均值升高比例密切正相关；AngⅡ水平与ABPM的醒时、睡眠SBP和DBP负荷升高密切正相关。RAAS水平与Ccr密切负相关。RAAS水平与β2-MG和NAG密切正相关。
3.PNS儿童24小时尿SNS水平(NA、A和DA)明显升高,高于正常对照和文献健康对照水平。PNS儿童SNS水平与血压指数、血压负荷正相关。PNS儿童的SNS水平Non-dipper组高于Dipper组,PNS儿童SNS水平与夜间下降率负相关。NA水平升高伴随着睡眠SBP均值和负荷升高。A水平升高伴随着睡眠DBP均值升高和夜间DBP下降率减低。DA水平升高伴随醒时DBP负荷、睡眠SBP负荷升高NA、A、DA的总体效果使血压平均水平升高、血压负荷升高和夜间BP下降率减低。NA水平与尿β2-MG量明显正相关。AngⅡ水平与24小时尿NA、A和DA水平正相关。
4.时间点蒙诺组7例中,5例Non-dipper,2例Dipper。5例Non-dipper血压升高时间段主要为睡眠时,结合Non-dipper因素,蒙诺用药时间点选择为睡前3小时；2例Dipper升高时间段也主要为睡眠时,蒙诺用药时间点选择也为睡前3小时。应用蒙诺的两组PNS儿童满2w时血压均值均较未用蒙诺组明显好转。蒙诺时间点用药组使ABPM血压均值、血压负荷的下降程度和夜间血压下降率提高程度明显大于常规蒙诺组和未用蒙诺组。
结论
1.ABPM发现PNS儿童高血压发病率高,且显示MHT高比例、Non-dipper高比例,这些血压升高指标和昼夜节律减弱与肾损害密切相关。重度MHT分类法重视了其对靶器官的损害。
2.PNS儿童RAAS活性升高,且可能主要通过AngⅡ升高血压并造成肾损害。
3.PNS儿童SNS活性升高使血压上升和动态血压节律减弱并可能是造成肾损伤主要原因之一。SNS活性与RAAS水平相互促进。
4.时间点法应用蒙诺更有效降低血压均值、负荷和改善夜间下降率,可能是较理想的降压药用法。未开展ABPM的医院选择蒙诺夜间睡前3小时用药可能更有效。
目的研究PNS儿童ABPM的变化与肾损害的关系。
方法采用ABPM仪对PNS儿童进行24小时动态血压监测,与手工CBP比较分析,并比较分析与肾损害的关系。
结果
1.原发性肾病综合征儿童ABPM比CBP具有更高的阳性率,动态血压升高101例(88.6%),可发现更高比例的血压均值、血压负荷升高,PNS儿童血压SBP升高比例大于DBP升高比例。PNS儿童SBP负荷大于DBP负荷。PNS初发、复发儿童血压均值、血压指数和负荷的差异无统计学意义(P>0.05)。不同病程(≤8w与>8w)血压均值、血压指数和负荷、BP夜间下降率差异无统计学意义(P>0.05)。
2.PNS儿童呈现MHT高发病率。轻重度隐匿性高血压45例(占全部PNS的39.5%),其中重度MHT18例(占全部PNS的15.8%)。
3.非杓型血压发病率高,共80例(70.2%)。PNS儿童睡眠BP升高比例大于醒时BP升高比例；PNS儿童睡眠血压负荷大于醒时血压负荷：PNS儿童非杓型血压发生率不同性别无明显差异；PNS儿童非杓型血压发生率与血压水平无明显相关性
4.Ccr与全日DBP指数、全日SBP负荷负相关；与夜间SBP下降率正相关；24小时尿尿蛋白定量与SBP、DBP指数正相关,与SBP、DBP夜间下降率负相关；尿β2-MG、尿NAG与DBP夜间下降率负相关。尿蛋白和Ccr与病理分型无明显相关性
结论
1. ABPM敏感度高,PNS儿童高血压发病率高,从而准确发现PNS儿童血压均值、血压负荷的升高程度,且发现SBP升高更明显。
2. ABPM能够发现高比例的MHT,利于高血压的早诊断早治疗。重度MHT分类法的建立利于评估靶器官损害机率。
3.PNS儿童非杓型血压发病率高,夜间BP升高更明显,标志着PNS儿童24小时动态血压节律的减低或消失。
4.PNS儿童ABP均值和负荷的升高可能是肾小球滤过率减低和肾损伤主要原因之一
5.PNS儿童非杓型血压可能是肾小球滤过率减低和肾损伤主要原因之一
目的研究PNS儿童RAAS系统水平的变化,探讨PNS儿童RAAS水平升高与ABP和肾损害的关系。
方法抽取卧位抗凝血,应用γ-放射免疫计数器测定PNS儿童血RAAS水平(PRA、AngⅡ和ALD)；将儿童血PRA、AngⅡ、ALD浓度与ABPM指标、肾损害指标作相关性分析。
结果
1.PNS儿童卧位血RAAS (PRA, AngⅡ、ALD)水平高于正常对照组。
2,AngⅡ水平与ABPM各个时段SBP、DBP均值升高密切正相关；AngⅡ水平与ABPM醒时、睡眠SBP和DBP负荷密切正相关。
3. RAAS水平与Ccr密切负相关。PRA与NAG正相关；PRA与Ccr负相关；AngⅡ水平与β2-MG正相关。
结论
1．PNS儿童RAAS水平升高。
2.PNS儿童RAAS活性主要通过AngⅡ促使血压上升。AngⅡ升高可能是促使ABP均值、负荷升高的因素之一
3。PNS儿童RAAS水平升高可能是肾功能减退和肾损害的重要因素之一。血PRA、AngⅡ、ALD含量升高可能直接或间接造成肾损害。
目的研究PNS儿童SNS系统活性的变化,探讨PNS儿童PNS水平升高与ABP和肾损害的关系,探讨SNS活性与RAAS水平的关系。
方法应用高效液相色谱电化学发光检测24小时尿SNS水平(NA、A和DA)；将患儿24小时尿NA、A和DA总量与ABPM指标、肾损害指标作相关性分析。
结果
1.PNS儿童24小时尿NA、A和DA总量明显升高,高于正常对照和文献健康对照水平。PNS儿童高血压组SNS水平高于正常血压组水平,PNS儿童SNS水平与血压指数、血压负荷正相关。
2.PNS儿童的SNS水平Non-dipper组高于Dipper组,PNS儿童SNS水平与夜间下降率负相关。
3.NA水平升高伴随着睡眠SBP均值和负荷升高。A水平升高伴随着睡眠DBP均值升高和夜间DBP下降率减低。DA水平升高伴随着醒时DBP负荷、睡眠SBP负荷升高。NA、A、DA的总体效果使血压升高、血压负荷升高和夜间BP下降率减低。
4.NA水平与尿β2-MG明显正相关。
5.AngⅡ水平与24小时尿NA、A和DA水平正相关。
结论
1.PNS儿童24小时尿NA、A和DA水平升高。
2.PNS儿童Non-dipper者SNS活性高。
3. NA、A、DA升高可能是促使ABP均值、负荷升高的因素之
4.NA水平升高可能是肾损害的因素之一
5.SNS活性与RAAS水平存在着相互促进作用。
目的研究PNS儿童ABPM对蒙诺疗效评价和对蒙诺新用法的探讨。
方法应用ABPM比较观察PNS儿童2w后血压改善情况,应用ABPM比较观察PNS儿童2w后蒙诺的不同用药方法(未用蒙诺组、常规蒙诺组和时间点蒙诺组)的血压改善情况。时间点蒙诺组是根据动态血压异常升高时段和夜间节律下降不良而选择蒙诺用药点,选择血压异常升高时段前3小时为蒙诺用药点。常规蒙诺组是按照目前的临床常规于每8：00应用蒙诺。
结果
1.时间点蒙诺组7例中,5例Non-dipper,2例Dipper。5例Non-dipper血压升高时间段主要为睡眠时,结合Non-dipper因素,蒙诺用药时间点选择为睡前3小时；2例Dipper升高时间段也主要为睡眠时,蒙诺用药时间点选择也为睡前3小时。
2.应用蒙诺的两组PNS儿童满2w时ABPM血压均值较未用蒙诺组明显好转。
3.蒙诺时间点用药组使ABPM血压均值、血压负荷的下降程度明显大于常规蒙诺组和未用蒙诺组。
4.蒙诺时间点用药组夜间血压下降率的提高程度明显大于常规蒙诺组和未用蒙诺组。
结论
1.蒙诺对高血压有显著的疗效,能够较好地减低血压均值。
2.蒙诺时间点用药法个性化用药,时间点法应用蒙诺可以更有效降低血压密集升高的血压值,使血压均值和负荷降低更明显。对血压均值、血压负荷的控制明显优于蒙诺常规用法,是一种理想的降压药应用方法。
3.蒙诺时间点用药法更明显地改善夜间血压下降率,逆转非杓型血压,改善24小时动态血压节律,使降压治疗更合理。
4.根据时间点的选择原则,时间点蒙诺组多数夜间睡前3小时应用,更有利于夜间高血压的控制和夜间下降率的改善,提示夜间睡前应用蒙诺可能更合理。未开展ABPM的医院PNS儿童可以选择夜间睡前3小时应用蒙诺可能更有效。
Backgrounds Primary nephrotic syndrome (PNS) was the most common of the renal disease with a long and complex course of treatment. There were a series of factors that promote its continuous development. PNS renal hypertension promoted to decrease the renal function and to enter into the end-stage renal disease (ESRD). Adult studies had shown that the progress of renal disease and systolic blood pressure (SBP), mean arterial blood pressure (MAP) showed significant positive correlation. GFR decline in chronic kidney disease was closely correlated with blood pressure, especially systolic blood pressure. Effectively controlling of blood pressure to protect the kidney function of patients was an important method.
PNS hypertension mechanisms were not yet entirely clear, might be involved in a variety of factors. Mechanisms of hypertension increasing kidney injury might include hemodynamic factors, non-hemodynamic factors. These might be related to upgrade level of sympathetic nervous system (SNS) and renin-angiotensin-aldosterone system (RAAS).
The existing relationship between hypertension and kidney disease research information was mainly for adults with hypertension and chronic renal damage in the study about typeⅡdiabetes with chronic renal damage and high blood pressure. The effects of hypertension on renal damage in Children might be similar to the adults. But there were differences certainly. However, there was lack of similar studies in children now. It needed researches urgently about hypertension and renal damages in children with chronic renal disease, especially PNS.
Ambulatory blood pressure monitoring (ABPM) avoiding human error could be a good response to blood pressure levels and blood pressure regularity. ABPM was more correlative to target organ damage than casual blood pressure (CBP). ABPM could also assess the control level of blood pressure exactly.
Angiotensin-converting enzyme inhibitors (ACEI) showed the protective effect on the kidney through controlling blood pressure and urinary protein excretion rate. Monopril (Fosinopril) is a kind of ACEI having dual channel clear mode:liver and kidney. Kidney damaged children will increase discharge of Monopril compensatory by the liver to remain the overall clearance of drug relatively stable avoiding drug accumulation. ABPM could give efficacy proof of application of ACEI and other antihypertensive drugs for children with PNS.
Objective To investigate the changes of ABPM value in children with PNS and its clinical significance. To research elevated RAAS activity in children with PNS and its relationship with ABPM and its pathogenesis role in PNS. To research elevated SNS activity in PNS children and its relationship with ABPM and its pathogenesis role in PNS. To explore the relationship between the elevated RAAS activity and the elevated SNS activity. Using ABPM evaluates the efficacy of Monopril and guide to create a new drug approach.
Methods Using ambulatory blood pressure instrument to record ambulatory blood pressure monitoring data in children with PNS and using ordinary mercury sphygmomanometer to survey casual blood pressure. Utilizingγ-radiation immune counter to detect plasma renin (PRA), angiotensinⅡ(AngⅡ) and aldosterone (ALD). To analyze the correlation between PRA, AngⅡand ALD level change and ABPM data. Utilizing high-performance liquid chromatography with electrochemical luminescence detection to measure 24-hour urine SNS levels. To analyze the correlation in SNS level changes, ABPM data and renal damages. To compare changes in ABPM among different medication methods after 2 weeks treatment. To analyze the significance of different medication methods in improving ABPM data. The Monopril point using group was selecting Monopril using point according ABPM levels and Non-dipper, and use Monopril 3 hours before ABP elevated intensively or sleeping. The Monopril routine using group according conventional medication used Monopril at 8am.
Results
1.101 cases (88.6%) of all kinds of ambulatory hypertension in total 114 cases of PNS showed the high incidence. Moreover, systolic blood pressure increased significantly. In addition, both light and severity masked hypertension possess 45 cases (39.5% of the total PNS cases), in which included severe masked hypertension 18 cases (15.8% of the total). It also indicated the high incidence of non-dipper blood pressure at 70.2% of the total PNS cases. Increasing of ABP mean and load in children with PNS decreased creatinine clearance rate and elevated 24-hour urine protein, urineβ2-microglobulin and urinary NAG. Children of non-dipper blood pressure with PNS significantly reduced creatinine clearance and increased 24-hour urine protein, urinary (32-MG and urinary NAG.
3. RAAS levels were significantly increased in PNS children. AngⅡlevels were closely correlated with ABP mean and ABP load. RAAS levels were closely negative correlated with Ccr. RAAS levels were closely negative correlated with urinary (32-MG and urinary NAG.
4. Urinary SNS levels were significantly increased in children with PNS and were closely positive related with non-dipper blood pressure. Urinary NA levels were closely positive correlated with SBP. Urinary A levels were closely positive correlated with DBP. Urinary DA levels were closely positive correlated with blood pressure load. SNS levels were closely positive correlated with urinaryβ2-MG.
5. RAAS levels were closely positive correlated with urine SNS levels in PNS children.
6. In 7 cases of Monopril time point medication Group included five cases of Non-dipper and 2 cases of Dipper. On one hand,5 cases of Non-dipper blood pressure mainly according evaluated stage of blood pressure and Non-dipper factors selected medication time 3 hours before sleep time. On the other hand, Monopril medication time also selected 3 hours before bed time in two cases of Dipper according to evaluated stage of blood pressure. ABP mean of the two groups of application Monopril after 2 weeks improved significantly than the unused Monopril. The ABPM data of the group selecting Monopril using point according ABPM levels and Non-dipper changed better in ABP levels than conventional medication at 8am.
Conclusion
1. ABPM helped to find the large proportion of MHT and showed a high rate of ambulatory hypertension in children with PNS. Moreover, ABPM found that children with high incidence of non-dipper blood pressure showing 24-hour ambulatory blood pressure rhythm abnormalities in children with PNS. In addition, high levels of ambulatory hypertension and decline of circadian rhythm of blood pressure prompted renal damage. Classification of severe MHT helped to pay more attention to the target organ damage.
2. RAAS activity increased in children with PNS which lifted the blood pressure mainly through AngⅡand caused kidney damage.
3. SNS activity increased in children with PNS which elevated children's blood pressure levels and declined the rhythm of ambulatory blood pressure which both causing renal damage. SNS activity and RAAS levels promoted each other.
4. Monopril time point medication applied more effectively to reduce the mean blood pressure, to decrease blood load and to improve the circadian rhythm that illustrated that it was an ideal blood pressure Medication approach. The hospital without ABPM can choose using Monopril 3 hours before going to bed at night.
Objective To study ABPM value changes and correlations of renal damage in children with primary nephrotic syndrome.
Methods 24-hour ambulatory blood pressure monitoring was done through ABPM instrument in children with primary nephrotic syndrome. ABPM was compared with CBP. To analyze the relationship in ABPM, CBP and renal damages.
Results
1. Nephrotic syndrome children have higher positive rate in blood pressure test by ABPM than CBP. All kinds of ambulatory hypertension arrived 101 cases (88.6%). There was a large proportion of high blood pressure mean, blood pressure load in which demonstrated SBP levels much higher than DBP and also illustrated SBP load greater than DBP load. Blood pressure mean and blood load had no significant differences between initial and relapse cases (P>0.05). Blood pressure mean and blood load had no significant differences between different course(≤8w and>8w) of disease(P>0.05).
2. Children with PNS showed high incidence of MHT which possessed 45 cases (39.5% of the total PNS) including severe MHT 18 cases (15.8% of the total PNS).
3. There was a high incidence of non-dipper blood pressure at 70.2%, Moreover, the blood pressure mean and blood pressure mean load increased higher in sleeping time than awaking time. However, the incidence of non-dipper blood pressure was not correlated with genders and blood pressure levels.
4. Ccr was negatively correlated with 24h systolic blood pressure levels and SBP load, and positive correlated with night SBP decreasing rates. Meanwhile,24 hours urinary protein positive correlated with SBP, DBP increasing index and negatively correlated with decreasing rate of SBP and DBP at night. Urinary (32-MG and urinary NAG were negatively related to DBP decreasing rate at night. Urine protein and Ccr were no significant correlated with renal pathological pattern.
Conclusion
1. ABPM had high sensitivity to find high incidence of hypertension in children with PNS, which accurately find the lifted degree of blood pressure mean and blood pressure load which illustrated SBP increasing more significantly than DBP.
2. It indicated the high incidence of MHT. That was conducive to provide early diagnosis and treatment of hypertension, classification of severe MHT benefited to establish the probability of target organ damage.
3. Night time blood pressure in children with PNS was significantly increased, and incidence of non-dipper blood pressure was high, which marked the 24-hour ambulatory blood pressure rhythm of children with PNS reduced or disappeared.
4. The increase of ABP mean and load in children with PNS caused glomerular filtration rate reducing and renal injury.
5. Non-dipper blood pressure in children with PNS lead to glomerular filtration rate reduce and renal damage.
Objective To study the RAAS levels changes in children with PNS. To explore the relationships in RAAS elevated levels, ABPM and renal damage in children with PNS.
Methods Applying Immuneγ-radiation counter measured RAAS(PRA, AngⅡand ALD) blood levels in children with PNS through decubitus anticoagulated blood. Correlation analysis in RAAS levels, ABP, renal damages and renal pathology.
Results
1. Blood PRA, AngⅡand ALD in children with PNS were significantly higher.
2. Angll levels were closely positive correlation to ABPM(SBP, DBP) mean increased ratio. AngⅡlevels were closely positive correlation to ABP load(SBP, DBP).
3. RAAS levels were closely negative correlation to Ccr. RAAS levels were closely positive correlation toβ2-MG and NAG.
Conclusion
1. RAAS levels were elevated in children with PNS.
2. RAAS activity in children with PNS prompted blood pressure primarily by AngⅡ. Angll might be one of the factors to lift BP mean and loads.
3. Elevated levels RAAS in children with PNS decreased renal function and increased renal damage. Increased Levels of blood PRA, AngⅡ, ALD might cause renal damage directly or indirectly.
Objective To study the SNS levels changes in children with PNS. To explore the relationships in SNS elevated levels, ABPM and renal damage in children with PNS.
Methods Utilizing high-performance liquid chromatography with electrochemical luminescence detection to measure 24-hour urine SNS (NA, A and DA)levels in children. To analyze the correlation in SNS level changes, ABPM data, renal damages and renal pathology.
Results
1.24-hour urinary NA, A and DA were significantly higher in children with PNS. The SNS levels were closely positive correlation to ABPM.
2. NA, A and DA levels in Non-dipper group increased significantly.
3. The overall effects of NA, A and DA were closely positive correlation to ABP mean and ABP load. They were also closely positive correlation to renal damages.
4. NA elevated levels were closely positive correlation to urine β2-MG.
5. AngⅡelevated levels were closely correlated to 24-hour urine NA, A and DA.
Conclusion
1. PNS children 24-hour urinary NA, A and DA levels were increased.
2. Non-dipper patients had increased levels of NA, A and DA. That showed that the Non-dipper patients sympathetic nerve excitability were higher.
3. NA, A and DA were the factors to promote ABP mean and ABP load increased.
4. NA elevated level might be one of the factors of renal damages.
5. RAAS elevated levels of AngⅡmay be directly increase the levels of SNS system.
Objective Using ABPM evaluated the efficacy of Monopril in children with PNS and guided to create a new drug approach.
Methods To compare changes in ABPM among different medication methods after 2 weeks treatment. To analyze the significance of different medication methods in improving ABPM figures. The Monopril point using group was selecting Monopril using point according ABPM levels and Non-dipper, and use Monopril 3 hours before ABP elevated intensively point or sleeping point. The Monopril routine using group according conventional medication used Monopril at 8am.
Results
1.7 cases of Monopril time point medication group included five cases of Non-dipper and 2 cases of Dipper. On one hand,5 cases of Non-dipper blood pressure mainly according to evaluated stage of blood pressure and Non-dipper factors selected medication time 3 hours before sleep time. On the other hand, Monopril medication time also selected 3 hours before went to bed in two cases of Dipper according to evaluated stage of blood pressure.
2. After 2 weeks application in two Monopril groups in children, the ABP mean and load decreased, meanwhile 24-hour ambulatory blood pressure rhythm improved.
3. ABP mean and load decreased significantly in Monopril time point using group than in the conventional group and the Group without using Monopril.
4. Night time decreasing rate increased significantly in Monopril time point using group than in the conventional group and the Group without using Monopril.
Conclusion
1. Monopril had the patency effect on high blood pressure control to reduce the ABP mean and load, and to lift the night time decreasing rate.
2. ABP mean and load decreased significantly in Monopril time point using group than in the conventional group, which might be more powerful control in ABP extremely raised period. Monopril time point using is an ideal antihypertensive drug application method.
3. Monopril time point medication method had high opportunity using pills before or in night which more significantly declined nocturnal blood pressure and reversed the non-dipper blood pressure, and improved 24-hour ambulatory blood pressure rhythm, which ensured controlling blood pressure more rationally.
4. Monopril time point medication applied more effectively to reduce the mean blood pressure, to decrease blood load and to improve the circadian rhythm that illustrated an ideal blood pressure medicine method. The hospital without ABPM can choose using Monopril 3 hours before going to bed at night.
PNS的高血压机制尚未完全明确,可能与多种因素有关,高血压对肾脏损伤的机制可能包括血流动力学因素、非血液动力学因素。可能与交感神经系统(sympathetic nervous system, SNS)和肾素-血管紧张素-醛固酮系统(renin-angiotensin-aldosterone system, RAAS)的亢进等有关。
已有的关于高血压与肾脏疾病关系研究的资料主要为成人高血压与慢性肾损害关系的研究以及Ⅱ型糖尿病慢性肾损害及血压变化的研究。儿童高血压对肾脏损害的影响可能类似于成人的表现,但必然有不同之处,目前儿童类似研究较少,因此慢性肾损害尤其是易复发而治疗困难的PNS儿童高血压与肾损害相互影响的研究急需开展。
动态血压监测刂(ambulatory Blood Pressure monitoring, ABPM)避免了人为误差,能较好反应血压水平和血压变化规律。ABPM显示的血压水平与靶器官损害的相关性优于随机血压(casual blood pressure, CBP), ABPM监测也能更好地评估血压控制水平。
血管紧张素转化酶抑制剂(angiotensin-converting enzyme inhibitor, ACEI)通过能够控制血压水平和降低尿蛋白排泄率等途径显示出对肾脏的保护作用,蒙诺(福辛普利)是具有肝肾双通道清除模式的ACEI,肾损害儿童通过肝脏代偿性排出增多,使药物总体清除保持相对稳定,避免了药物蓄积。ABPM能为PNS儿童应用蒙诺等ACEI降压药提供疗效依据。
目的研究PNS儿童ABP的变化及临床意义；探讨PNS儿童RAAS活性升高与ABP的关系以及与PNS发病机制的关系；探讨SNS活性升高与ABP的关系和与PNS发病机制的关系；探讨PNS儿童RAAS活性升高与SNS活性升高的关系；探讨ABPM评价蒙诺疗效的运用和依靠ABPM创建新的用药方法。
方法采用动态血压仪对PNS儿童进行动态血压监测并应用普通水银血压计进行随机血压测量；应用γ-放射免疫计数器检测血肾素(plasma renin, PRA)、血管紧张素Ⅱ(AngiotensinⅡ, AngⅡ)和醛固酮(aldosterone, ALD)水平,并与ABP变化作相关性分析；应用高效液相色谱电化学发光检测24小时尿SNS的去甲肾上腺素(noradrenaline, NA)、肾上腺素(adrenaline, A)、多巴胺(dopamine,DA)水平,并与ABP变化作相关性分析；蒙诺不同用药方法比较观察2w后ABPM的变化,分析蒙诺不同用药方法与ABP变化的关系。
结果
1.原发性肾病综合征儿童ABPM比CBP具有更高的阳性率,动态高血压101例(88.6%),发病率高。PNS儿童SBP升高更明显。轻重度隐匿性高血压45例(占全部PNS的39.5%),其中重度MHT18例(占全部PNS的15.8%)。非杓型血压发病率高,共80例(70.2%)。ABP均值和负荷的升高的PNS儿童出现明显的内生肌酐清除率减低和24小时尿蛋白、尿β2-微球蛋白(β2-microglobulin,02-MG)和尿N-乙酰葡糖胺酶(N-acetylglucosaminidase, NAG)增多。非杓型血压PNS儿童明显的内生肌酐清除率(creatinine clearance, Ccr)减低和24小时尿蛋白、尿β2-MG和尿NAG增多。
2.PNS组卧位血RAAS水平比正常对照组明显升高。AngⅡ水平与ABPM各个时段SBP、舒张压(diastolic blood pressure, DBP)均值升高比例密切正相关；AngⅡ水平与ABPM的醒时、睡眠SBP和DBP负荷升高密切正相关。RAAS水平与Ccr密切负相关。RAAS水平与β2-MG和NAG密切正相关。
3.PNS儿童24小时尿SNS水平(NA、A和DA)明显升高,高于正常对照和文献健康对照水平。PNS儿童SNS水平与血压指数、血压负荷正相关。PNS儿童的SNS水平Non-dipper组高于Dipper组,PNS儿童SNS水平与夜间下降率负相关。NA水平升高伴随着睡眠SBP均值和负荷升高。A水平升高伴随着睡眠DBP均值升高和夜间DBP下降率减低。DA水平升高伴随醒时DBP负荷、睡眠SBP负荷升高NA、A、DA的总体效果使血压平均水平升高、血压负荷升高和夜间BP下降率减低。NA水平与尿β2-MG量明显正相关。AngⅡ水平与24小时尿NA、A和DA水平正相关。
4.时间点蒙诺组7例中,5例Non-dipper,2例Dipper。5例Non-dipper血压升高时间段主要为睡眠时,结合Non-dipper因素,蒙诺用药时间点选择为睡前3小时；2例Dipper升高时间段也主要为睡眠时,蒙诺用药时间点选择也为睡前3小时。应用蒙诺的两组PNS儿童满2w时血压均值均较未用蒙诺组明显好转。蒙诺时间点用药组使ABPM血压均值、血压负荷的下降程度和夜间血压下降率提高程度明显大于常规蒙诺组和未用蒙诺组。
结论
1.ABPM发现PNS儿童高血压发病率高,且显示MHT高比例、Non-dipper高比例,这些血压升高指标和昼夜节律减弱与肾损害密切相关。重度MHT分类法重视了其对靶器官的损害。
2.PNS儿童RAAS活性升高,且可能主要通过AngⅡ升高血压并造成肾损害。
3.PNS儿童SNS活性升高使血压上升和动态血压节律减弱并可能是造成肾损伤主要原因之一。SNS活性与RAAS水平相互促进。
4.时间点法应用蒙诺更有效降低血压均值、负荷和改善夜间下降率,可能是较理想的降压药用法。未开展ABPM的医院选择蒙诺夜间睡前3小时用药可能更有效。
目的研究PNS儿童ABPM的变化与肾损害的关系。
方法采用ABPM仪对PNS儿童进行24小时动态血压监测,与手工CBP比较分析,并比较分析与肾损害的关系。
结果
1.原发性肾病综合征儿童ABPM比CBP具有更高的阳性率,动态血压升高101例(88.6%),可发现更高比例的血压均值、血压负荷升高,PNS儿童血压SBP升高比例大于DBP升高比例。PNS儿童SBP负荷大于DBP负荷。PNS初发、复发儿童血压均值、血压指数和负荷的差异无统计学意义(P>0.05)。不同病程(≤8w与>8w)血压均值、血压指数和负荷、BP夜间下降率差异无统计学意义(P>0.05)。
2.PNS儿童呈现MHT高发病率。轻重度隐匿性高血压45例(占全部PNS的39.5%),其中重度MHT18例(占全部PNS的15.8%)。
3.非杓型血压发病率高,共80例(70.2%)。PNS儿童睡眠BP升高比例大于醒时BP升高比例；PNS儿童睡眠血压负荷大于醒时血压负荷：PNS儿童非杓型血压发生率不同性别无明显差异；PNS儿童非杓型血压发生率与血压水平无明显相关性
4.Ccr与全日DBP指数、全日SBP负荷负相关；与夜间SBP下降率正相关；24小时尿尿蛋白定量与SBP、DBP指数正相关,与SBP、DBP夜间下降率负相关；尿β2-MG、尿NAG与DBP夜间下降率负相关。尿蛋白和Ccr与病理分型无明显相关性
结论
1. ABPM敏感度高,PNS儿童高血压发病率高,从而准确发现PNS儿童血压均值、血压负荷的升高程度,且发现SBP升高更明显。
2. ABPM能够发现高比例的MHT,利于高血压的早诊断早治疗。重度MHT分类法的建立利于评估靶器官损害机率。
3.PNS儿童非杓型血压发病率高,夜间BP升高更明显,标志着PNS儿童24小时动态血压节律的减低或消失。
4.PNS儿童ABP均值和负荷的升高可能是肾小球滤过率减低和肾损伤主要原因之一
5.PNS儿童非杓型血压可能是肾小球滤过率减低和肾损伤主要原因之一
目的研究PNS儿童RAAS系统水平的变化,探讨PNS儿童RAAS水平升高与ABP和肾损害的关系。
方法抽取卧位抗凝血,应用γ-放射免疫计数器测定PNS儿童血RAAS水平(PRA、AngⅡ和ALD)；将儿童血PRA、AngⅡ、ALD浓度与ABPM指标、肾损害指标作相关性分析。
结果
1.PNS儿童卧位血RAAS (PRA, AngⅡ、ALD)水平高于正常对照组。
2,AngⅡ水平与ABPM各个时段SBP、DBP均值升高密切正相关；AngⅡ水平与ABPM醒时、睡眠SBP和DBP负荷密切正相关。
3. RAAS水平与Ccr密切负相关。PRA与NAG正相关；PRA与Ccr负相关；AngⅡ水平与β2-MG正相关。
结论
1．PNS儿童RAAS水平升高。
2.PNS儿童RAAS活性主要通过AngⅡ促使血压上升。AngⅡ升高可能是促使ABP均值、负荷升高的因素之一
3。PNS儿童RAAS水平升高可能是肾功能减退和肾损害的重要因素之一。血PRA、AngⅡ、ALD含量升高可能直接或间接造成肾损害。
目的研究PNS儿童SNS系统活性的变化,探讨PNS儿童PNS水平升高与ABP和肾损害的关系,探讨SNS活性与RAAS水平的关系。
方法应用高效液相色谱电化学发光检测24小时尿SNS水平(NA、A和DA)；将患儿24小时尿NA、A和DA总量与ABPM指标、肾损害指标作相关性分析。
结果
1.PNS儿童24小时尿NA、A和DA总量明显升高,高于正常对照和文献健康对照水平。PNS儿童高血压组SNS水平高于正常血压组水平,PNS儿童SNS水平与血压指数、血压负荷正相关。
2.PNS儿童的SNS水平Non-dipper组高于Dipper组,PNS儿童SNS水平与夜间下降率负相关。
3.NA水平升高伴随着睡眠SBP均值和负荷升高。A水平升高伴随着睡眠DBP均值升高和夜间DBP下降率减低。DA水平升高伴随着醒时DBP负荷、睡眠SBP负荷升高。NA、A、DA的总体效果使血压升高、血压负荷升高和夜间BP下降率减低。
4.NA水平与尿β2-MG明显正相关。
5.AngⅡ水平与24小时尿NA、A和DA水平正相关。
结论
1.PNS儿童24小时尿NA、A和DA水平升高。
2.PNS儿童Non-dipper者SNS活性高。
3. NA、A、DA升高可能是促使ABP均值、负荷升高的因素之
4.NA水平升高可能是肾损害的因素之一
5.SNS活性与RAAS水平存在着相互促进作用。
目的研究PNS儿童ABPM对蒙诺疗效评价和对蒙诺新用法的探讨。
方法应用ABPM比较观察PNS儿童2w后血压改善情况,应用ABPM比较观察PNS儿童2w后蒙诺的不同用药方法(未用蒙诺组、常规蒙诺组和时间点蒙诺组)的血压改善情况。时间点蒙诺组是根据动态血压异常升高时段和夜间节律下降不良而选择蒙诺用药点,选择血压异常升高时段前3小时为蒙诺用药点。常规蒙诺组是按照目前的临床常规于每8：00应用蒙诺。
结果
1.时间点蒙诺组7例中,5例Non-dipper,2例Dipper。5例Non-dipper血压升高时间段主要为睡眠时,结合Non-dipper因素,蒙诺用药时间点选择为睡前3小时；2例Dipper升高时间段也主要为睡眠时,蒙诺用药时间点选择也为睡前3小时。
2.应用蒙诺的两组PNS儿童满2w时ABPM血压均值较未用蒙诺组明显好转。
3.蒙诺时间点用药组使ABPM血压均值、血压负荷的下降程度明显大于常规蒙诺组和未用蒙诺组。
4.蒙诺时间点用药组夜间血压下降率的提高程度明显大于常规蒙诺组和未用蒙诺组。
结论
1.蒙诺对高血压有显著的疗效,能够较好地减低血压均值。
2.蒙诺时间点用药法个性化用药,时间点法应用蒙诺可以更有效降低血压密集升高的血压值,使血压均值和负荷降低更明显。对血压均值、血压负荷的控制明显优于蒙诺常规用法,是一种理想的降压药应用方法。
3.蒙诺时间点用药法更明显地改善夜间血压下降率,逆转非杓型血压,改善24小时动态血压节律,使降压治疗更合理。
4.根据时间点的选择原则,时间点蒙诺组多数夜间睡前3小时应用,更有利于夜间高血压的控制和夜间下降率的改善,提示夜间睡前应用蒙诺可能更合理。未开展ABPM的医院PNS儿童可以选择夜间睡前3小时应用蒙诺可能更有效。
Backgrounds Primary nephrotic syndrome (PNS) was the most common of the renal disease with a long and complex course of treatment. There were a series of factors that promote its continuous development. PNS renal hypertension promoted to decrease the renal function and to enter into the end-stage renal disease (ESRD). Adult studies had shown that the progress of renal disease and systolic blood pressure (SBP), mean arterial blood pressure (MAP) showed significant positive correlation. GFR decline in chronic kidney disease was closely correlated with blood pressure, especially systolic blood pressure. Effectively controlling of blood pressure to protect the kidney function of patients was an important method.
PNS hypertension mechanisms were not yet entirely clear, might be involved in a variety of factors. Mechanisms of hypertension increasing kidney injury might include hemodynamic factors, non-hemodynamic factors. These might be related to upgrade level of sympathetic nervous system (SNS) and renin-angiotensin-aldosterone system (RAAS).
The existing relationship between hypertension and kidney disease research information was mainly for adults with hypertension and chronic renal damage in the study about typeⅡdiabetes with chronic renal damage and high blood pressure. The effects of hypertension on renal damage in Children might be similar to the adults. But there were differences certainly. However, there was lack of similar studies in children now. It needed researches urgently about hypertension and renal damages in children with chronic renal disease, especially PNS.
Ambulatory blood pressure monitoring (ABPM) avoiding human error could be a good response to blood pressure levels and blood pressure regularity. ABPM was more correlative to target organ damage than casual blood pressure (CBP). ABPM could also assess the control level of blood pressure exactly.
Angiotensin-converting enzyme inhibitors (ACEI) showed the protective effect on the kidney through controlling blood pressure and urinary protein excretion rate. Monopril (Fosinopril) is a kind of ACEI having dual channel clear mode:liver and kidney. Kidney damaged children will increase discharge of Monopril compensatory by the liver to remain the overall clearance of drug relatively stable avoiding drug accumulation. ABPM could give efficacy proof of application of ACEI and other antihypertensive drugs for children with PNS.
Objective To investigate the changes of ABPM value in children with PNS and its clinical significance. To research elevated RAAS activity in children with PNS and its relationship with ABPM and its pathogenesis role in PNS. To research elevated SNS activity in PNS children and its relationship with ABPM and its pathogenesis role in PNS. To explore the relationship between the elevated RAAS activity and the elevated SNS activity. Using ABPM evaluates the efficacy of Monopril and guide to create a new drug approach.
Methods Using ambulatory blood pressure instrument to record ambulatory blood pressure monitoring data in children with PNS and using ordinary mercury sphygmomanometer to survey casual blood pressure. Utilizingγ-radiation immune counter to detect plasma renin (PRA), angiotensinⅡ(AngⅡ) and aldosterone (ALD). To analyze the correlation between PRA, AngⅡand ALD level change and ABPM data. Utilizing high-performance liquid chromatography with electrochemical luminescence detection to measure 24-hour urine SNS levels. To analyze the correlation in SNS level changes, ABPM data and renal damages. To compare changes in ABPM among different medication methods after 2 weeks treatment. To analyze the significance of different medication methods in improving ABPM data. The Monopril point using group was selecting Monopril using point according ABPM levels and Non-dipper, and use Monopril 3 hours before ABP elevated intensively or sleeping. The Monopril routine using group according conventional medication used Monopril at 8am.
Results
1.101 cases (88.6%) of all kinds of ambulatory hypertension in total 114 cases of PNS showed the high incidence. Moreover, systolic blood pressure increased significantly. In addition, both light and severity masked hypertension possess 45 cases (39.5% of the total PNS cases), in which included severe masked hypertension 18 cases (15.8% of the total). It also indicated the high incidence of non-dipper blood pressure at 70.2% of the total PNS cases. Increasing of ABP mean and load in children with PNS decreased creatinine clearance rate and elevated 24-hour urine protein, urineβ2-microglobulin and urinary NAG. Children of non-dipper blood pressure with PNS significantly reduced creatinine clearance and increased 24-hour urine protein, urinary (32-MG and urinary NAG.
3. RAAS levels were significantly increased in PNS children. AngⅡlevels were closely correlated with ABP mean and ABP load. RAAS levels were closely negative correlated with Ccr. RAAS levels were closely negative correlated with urinary (32-MG and urinary NAG.
4. Urinary SNS levels were significantly increased in children with PNS and were closely positive related with non-dipper blood pressure. Urinary NA levels were closely positive correlated with SBP. Urinary A levels were closely positive correlated with DBP. Urinary DA levels were closely positive correlated with blood pressure load. SNS levels were closely positive correlated with urinaryβ2-MG.
5. RAAS levels were closely positive correlated with urine SNS levels in PNS children.
6. In 7 cases of Monopril time point medication Group included five cases of Non-dipper and 2 cases of Dipper. On one hand,5 cases of Non-dipper blood pressure mainly according evaluated stage of blood pressure and Non-dipper factors selected medication time 3 hours before sleep time. On the other hand, Monopril medication time also selected 3 hours before bed time in two cases of Dipper according to evaluated stage of blood pressure. ABP mean of the two groups of application Monopril after 2 weeks improved significantly than the unused Monopril. The ABPM data of the group selecting Monopril using point according ABPM levels and Non-dipper changed better in ABP levels than conventional medication at 8am.
Conclusion
1. ABPM helped to find the large proportion of MHT and showed a high rate of ambulatory hypertension in children with PNS. Moreover, ABPM found that children with high incidence of non-dipper blood pressure showing 24-hour ambulatory blood pressure rhythm abnormalities in children with PNS. In addition, high levels of ambulatory hypertension and decline of circadian rhythm of blood pressure prompted renal damage. Classification of severe MHT helped to pay more attention to the target organ damage.
2. RAAS activity increased in children with PNS which lifted the blood pressure mainly through AngⅡand caused kidney damage.
3. SNS activity increased in children with PNS which elevated children's blood pressure levels and declined the rhythm of ambulatory blood pressure which both causing renal damage. SNS activity and RAAS levels promoted each other.
4. Monopril time point medication applied more effectively to reduce the mean blood pressure, to decrease blood load and to improve the circadian rhythm that illustrated that it was an ideal blood pressure Medication approach. The hospital without ABPM can choose using Monopril 3 hours before going to bed at night.
Objective To study ABPM value changes and correlations of renal damage in children with primary nephrotic syndrome.
Methods 24-hour ambulatory blood pressure monitoring was done through ABPM instrument in children with primary nephrotic syndrome. ABPM was compared with CBP. To analyze the relationship in ABPM, CBP and renal damages.
Results
1. Nephrotic syndrome children have higher positive rate in blood pressure test by ABPM than CBP. All kinds of ambulatory hypertension arrived 101 cases (88.6%). There was a large proportion of high blood pressure mean, blood pressure load in which demonstrated SBP levels much higher than DBP and also illustrated SBP load greater than DBP load. Blood pressure mean and blood load had no significant differences between initial and relapse cases (P>0.05). Blood pressure mean and blood load had no significant differences between different course(≤8w and>8w) of disease(P>0.05).
2. Children with PNS showed high incidence of MHT which possessed 45 cases (39.5% of the total PNS) including severe MHT 18 cases (15.8% of the total PNS).
3. There was a high incidence of non-dipper blood pressure at 70.2%, Moreover, the blood pressure mean and blood pressure mean load increased higher in sleeping time than awaking time. However, the incidence of non-dipper blood pressure was not correlated with genders and blood pressure levels.
4. Ccr was negatively correlated with 24h systolic blood pressure levels and SBP load, and positive correlated with night SBP decreasing rates. Meanwhile,24 hours urinary protein positive correlated with SBP, DBP increasing index and negatively correlated with decreasing rate of SBP and DBP at night. Urinary (32-MG and urinary NAG were negatively related to DBP decreasing rate at night. Urine protein and Ccr were no significant correlated with renal pathological pattern.
Conclusion
1. ABPM had high sensitivity to find high incidence of hypertension in children with PNS, which accurately find the lifted degree of blood pressure mean and blood pressure load which illustrated SBP increasing more significantly than DBP.
2. It indicated the high incidence of MHT. That was conducive to provide early diagnosis and treatment of hypertension, classification of severe MHT benefited to establish the probability of target organ damage.
3. Night time blood pressure in children with PNS was significantly increased, and incidence of non-dipper blood pressure was high, which marked the 24-hour ambulatory blood pressure rhythm of children with PNS reduced or disappeared.
4. The increase of ABP mean and load in children with PNS caused glomerular filtration rate reducing and renal injury.
5. Non-dipper blood pressure in children with PNS lead to glomerular filtration rate reduce and renal damage.
Objective To study the RAAS levels changes in children with PNS. To explore the relationships in RAAS elevated levels, ABPM and renal damage in children with PNS.
Methods Applying Immuneγ-radiation counter measured RAAS(PRA, AngⅡand ALD) blood levels in children with PNS through decubitus anticoagulated blood. Correlation analysis in RAAS levels, ABP, renal damages and renal pathology.
Results
1. Blood PRA, AngⅡand ALD in children with PNS were significantly higher.
2. Angll levels were closely positive correlation to ABPM(SBP, DBP) mean increased ratio. AngⅡlevels were closely positive correlation to ABP load(SBP, DBP).
3. RAAS levels were closely negative correlation to Ccr. RAAS levels were closely positive correlation toβ2-MG and NAG.
Conclusion
1. RAAS levels were elevated in children with PNS.
2. RAAS activity in children with PNS prompted blood pressure primarily by AngⅡ. Angll might be one of the factors to lift BP mean and loads.
3. Elevated levels RAAS in children with PNS decreased renal function and increased renal damage. Increased Levels of blood PRA, AngⅡ, ALD might cause renal damage directly or indirectly.
Objective To study the SNS levels changes in children with PNS. To explore the relationships in SNS elevated levels, ABPM and renal damage in children with PNS.
Methods Utilizing high-performance liquid chromatography with electrochemical luminescence detection to measure 24-hour urine SNS (NA, A and DA)levels in children. To analyze the correlation in SNS level changes, ABPM data, renal damages and renal pathology.
Results
1.24-hour urinary NA, A and DA were significantly higher in children with PNS. The SNS levels were closely positive correlation to ABPM.
2. NA, A and DA levels in Non-dipper group increased significantly.
3. The overall effects of NA, A and DA were closely positive correlation to ABP mean and ABP load. They were also closely positive correlation to renal damages.
4. NA elevated levels were closely positive correlation to urine β2-MG.
5. AngⅡelevated levels were closely correlated to 24-hour urine NA, A and DA.
Conclusion
1. PNS children 24-hour urinary NA, A and DA levels were increased.
2. Non-dipper patients had increased levels of NA, A and DA. That showed that the Non-dipper patients sympathetic nerve excitability were higher.
3. NA, A and DA were the factors to promote ABP mean and ABP load increased.
4. NA elevated level might be one of the factors of renal damages.
5. RAAS elevated levels of AngⅡmay be directly increase the levels of SNS system.
Objective Using ABPM evaluated the efficacy of Monopril in children with PNS and guided to create a new drug approach.
Methods To compare changes in ABPM among different medication methods after 2 weeks treatment. To analyze the significance of different medication methods in improving ABPM figures. The Monopril point using group was selecting Monopril using point according ABPM levels and Non-dipper, and use Monopril 3 hours before ABP elevated intensively point or sleeping point. The Monopril routine using group according conventional medication used Monopril at 8am.
Results
1.7 cases of Monopril time point medication group included five cases of Non-dipper and 2 cases of Dipper. On one hand,5 cases of Non-dipper blood pressure mainly according to evaluated stage of blood pressure and Non-dipper factors selected medication time 3 hours before sleep time. On the other hand, Monopril medication time also selected 3 hours before went to bed in two cases of Dipper according to evaluated stage of blood pressure.
2. After 2 weeks application in two Monopril groups in children, the ABP mean and load decreased, meanwhile 24-hour ambulatory blood pressure rhythm improved.
3. ABP mean and load decreased significantly in Monopril time point using group than in the conventional group and the Group without using Monopril.
4. Night time decreasing rate increased significantly in Monopril time point using group than in the conventional group and the Group without using Monopril.
Conclusion
1. Monopril had the patency effect on high blood pressure control to reduce the ABP mean and load, and to lift the night time decreasing rate.
2. ABP mean and load decreased significantly in Monopril time point using group than in the conventional group, which might be more powerful control in ABP extremely raised period. Monopril time point using is an ideal antihypertensive drug application method.
3. Monopril time point medication method had high opportunity using pills before or in night which more significantly declined nocturnal blood pressure and reversed the non-dipper blood pressure, and improved 24-hour ambulatory blood pressure rhythm, which ensured controlling blood pressure more rationally.
4. Monopril time point medication applied more effectively to reduce the mean blood pressure, to decrease blood load and to improve the circadian rhythm that illustrated an ideal blood pressure medicine method. The hospital without ABPM can choose using Monopril 3 hours before going to bed at night.
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