腎移植高血壓患者藥學(xué)監(jiān)護講課課件

腎移植高血壓患者藥學(xué)監(jiān)護腎移植高血壓患者藥學(xué)監(jiān)護1（優(yōu)選）腎移植高血壓患者藥學(xué)監(jiān)護（優(yōu)選）腎移植高血壓患者藥學(xué)監(jiān)護2TutoneVK,etal.Pharmaceutical30mgQ12hRTRs的平均動脈壓每升高10mmHg,其移植腎臟功能衰竭的發(fā)生率上升30%CurrentmedicationPharmaceuticalSaltrestrictionOptimalbloodlevelsofBloodpressure>=140/90Assessinformation(patientassess)ClinTransplant2005:19:181–192.MedicalCare40mgqdTreatmenthypertension

Drug130/85mmHgforrenaltransplantrecipientswithoutproteinuriaCaseStudyPatientdetails(renaltransplantation)

Number:4438420Sex:MaleWeight:63kgHigh:160cmDateofBirth:1943/02/09Age:63yearsDisease:ChronicnephritisOperationdate:

2006/04/19CadavericColdischemiatime(hours):12

Heatischemiatime(minutes):5TutoneVK,etal.CaseStudyPat3CurrentmedicationImmunosuppressiveregimentsCyclosporine100mgBid125mgBidALG250mgQDMizoribine100mgQD,50mgQNMycophenolatemofetil750mgBidMethylprednisolone500mgQd3d

Prednisolone30mgQdCurrentmedicationImmunosuppre4CurrentantihypertensivemedicationsMetoprolol12.5mgQ12hNifedipineControlledreleased30mgqd30mgQ12hEnalapril10mgQ12hFurosemide40mgtid

40mgqd

Currentantihypertensivemedic5172/89172/896患者醫(yī)師藥劑師護士MedicalCareNursingCareDrugInformation＆Pharmaceutical

CareInformationDrugInformation＆Pharmaceutical

CareInformation以患者為中心、以人為本PharmaceuticalCare患者醫(yī)師藥劑師護士MedicalCareNursing7PharmaceuticalcareandpatientassessmentInitiaterelationshipwithpatient

Gatherpatientinformation(subjectiveandobjective)Assessinformation(patientassess)CompletetheinterventionDeveloppharmaceuticalcareplan

Implementfollow-upPharmaceuticalcareandpatien8GraftandpatientsurvivalKaplan–MeieranalyseswiththepopulationdividedintoquintilesofsystolicBPTutoneVK,etal.ClinTransplant2005:19:181–192.GraftandpatientsurvivalKap9GraftandpatientsurvivalKaplan–Meieranalyseswiththepopulation

dividedintoquintilesofdiastolicBP

TutoneVK,etal.ClinTransplant2005:19:181–192.GraftandpatientsurvivalKap10Summaryofantihypertensiveswithpatientandgraftoutcomes

BB,beta-blocker;CC,calciumchannelblocker;Loop,loopdiuretic;ACEI,angiotensinconvertingenzymeinhibitor;ARB,angiotensinreceptorantagonistSummaryofantihypertensivesw11DiagnosisandtreatmentofhypertensionintherenaltransplantrecipientContinueanti-hypertensivetherapyReassessperiodicallyAdministeranti-hypertensiveAgent(CA,ACEI,orotherBloodpressure>=140/90StableGFR?InterventionfailstonormalizeBPConsidersaltrestrictionand/ordiureticMultidrugregimen;addagentsofdifferentclassesasnecessaryReducedoseofcyclosporineortacrolimusEvaluateallograftfunctionOptimalbloodlevelsofcyclosporineortacrolimusECGvolumestatusacceptable?Adequateresponsetotherapy?AcceptableADR?Adequateresponsetotherapy?Re-evaluateallograftfunctionanddrugtherapyConsiderTRASNoYesYesYesNoNoNoNoYesYesYesDiagnosisandtreatmentofhyp12Frequencyofhypertension6085%renaltransplantrecipients90%renaltransplantrecipientsadministratedCsAFrequencyofhypertension608513acceptable?Ifthesevariablesarestable,itisreasonabletoproceedwithantihypertensivetherapyAdequateresponsetotherapy?ACEIandARBarealsoeffective;theiruserequiresclosemonitoringofrenalfunction,serumpotassiumlevels,andhematocritlevels(subjectiveandobjective)TutoneVK,etal.ACEI,angiotensinconvertingenzymeinhibitor;ARB,angiotensinreceptorantagonistMedicalCareTutoneVK,etal.Bloodpressurereadingsconsistentlyover140/90mmHgDrugInformation＆Verapamil,diltiazem,nicardipine,andmibefradilincreasebloodlevelsofcyclosporineandtacrolimusandshouldbeusedwithcaution.Causeofhypertension免疫抑制劑的使用移植腎相關(guān)的因素急、慢性排斥反應(yīng)慢性移植腎病腎動脈狹窄,復(fù)發(fā)性或新發(fā)性腎病,藥物腎毒性,尿路梗阻原腎高腎素潴留紅細(xì)胞增多癥acceptable?Causeofhypertensi14Bloodpressurereadingsconsistentlyover140/90mmHg(subjectiveandobjective)GraftandpatientsurvivalKaplan–MeieranalyseswiththepopulationCalciumantagonists(CA)areeffectiveagentsandmayoffertheaddedbenefitofattenuatingcyclosporineinducedchangesinrenalhemodynamics.Assessmentofallograftfunction,extracellularfluidvolume(ECF)status,andimmunosuppressivedosingBB,beta-blocker;CC,calciumchannelblocker;Loop,loopdiuretic;ClinTransplant2005:19:181–192.StableGFR?DrugInformation＆(subjectiveandobjective)ACEI,angiotensinconvertingenzymeinhibitor;ARB,angiotensinreceptorantagonistanddrugtherapy130/85mmHgforrenaltransplantrecipientswithoutproteinuriaInitiaterelationshipwithpatientCurrentantihypertensivemedicationsRiskFactor免疫抑制劑的升壓移植腎功能受損移植腎動脈狹窄RTRs的平均動脈壓每升高10mmHg,其移植腎臟功能衰竭的發(fā)生率上升30%腎移植后合并血壓升高者急性排斥反應(yīng)發(fā)生率遠(yuǎn)遠(yuǎn)高于血壓降低者尸體腎移植較活體腎移植發(fā)生率高Bloodpressurereadingsconsist15DiagnosishypertensionBloodpressurereadingsconsistentlyover140/90mmHgAssessmentofallograftfunction,extracellularfluidvolume(ECF)status,andimmunosuppressivedosingIfthesevariablesarestable,itisreasonabletoproceedwithantihypertensivetherapyDiagnosishypertensionBloodpr16Treatmenthypertension130/85mmHgforrenaltransplantrecipientswithoutproteinuria125/75mmHgforproteinuricpatients

Treatmenthypertension130/8517Bloodpressurereadingsconsistentlyover140/90mmHgacceptable?InitiaterelationshipwithpatientAntihypertensivemedicationsintherenaltransplantrecipientStableGFR?CalciumchannelblockIfthesevariablesarestable,itisreasonabletoproceedwithantihypertensivetherapyGraftandpatientsurvivalKaplan–Meieranalyseswiththepopulation

dividedintoquintilesofdiastolicBPCurrentmedicationCurrentantihypertensivemedicationsACEinhibitor6085%renaltransplantrecipientsTreatmenthypertension

DrugModificationoftheimmunosuppressivetherapyCalciumchannelblockACEinhibitorARBBloodpressurereadingsconsist18(subjectiveandobjective)Bloodpressurereadingsconsistentlyover140/90mmHgPharmaceuticalcareandpatientassessmentTutoneVK,etal.Adequateresponsetotherapy?Treatmenthypertension

nondrugImmunosuppressiveregimentsMedicalCareClinTransplant2005:19:181–192.DiagnosisandtreatmentofhypertensionintherenaltransplantrecipientBloodpressure>=140/90StableGFR?Treatmenthypertension

nondrugAvoidanceofanincreaseinbodyweightSaltrestrictionExerciseSurgery(subjectiveandobjective)Trea19TutoneVK,etal.InitiaterelationshipwithpatientanddrugtherapyTreatmenthypertension

nondrugAdministeranti-hypertensive(subjectiveandobjective)Adequateresponsetotherapy?SaltrestrictionAcceptableADR?RTRs的平均動脈壓每升高10mmHg,其移植腎臟功能衰竭的發(fā)生率上升30%130/85mmHgforrenaltransplantrecipientswithoutproteinuriaPharmaceuticalAntihypertensivemedicationsintherenaltransplantrecipientCalciumantagonists(CA)areeffectiveagentsandmayoffertheaddedbenefitofattenuatingcyclosporineinducedchangesinrenalhemodynamics.Verapamil,diltiazem,nicardipine,andmibefradilincreasebloodlevelsofcyclosporineandtacrolimusandshouldbeusedwithcaution.ACEIandARBarealsoeffective;theiruserequiresclosemonitoringofrenalfunction,serumpotassiumlevels,andhematocritlevelsDiureticsfrequentlyareusefuladjunctstotherapyinrecipientsowingtothesaltretentionthatoftenaccompaniescyclosporineTutoneVK,etal.Antihypertens20參與臨床用藥工作發(fā)現(xiàn)解決潛在的或?qū)嶋H存在的用藥問題預(yù)防參與臨床用藥工作發(fā)現(xiàn)21藥物治療中的問題與適應(yīng)證不符需要其他的藥物治療藥物治療無效藥物劑量過低藥物治療中出現(xiàn)的不良反應(yīng)藥物劑量過高順從性或依從性較差藥物治療中的問題與適應(yīng)證不符22DrugInformation＆Treatmenthypertension

Drug125mgBidContinueanti-hypertensivetherapy6085%renaltransplantrecipientsAssessmentofallograftfunction,extracellularfluidvolume(ECF)status,an