肾移植高血压患者药学监护

肾移植高血压患者药学监护胡永芳MajorContentsCauseofhypertensionintherenaltransplantationTreatmentofhypertensionintherenaltransplantrecipientAnti-hypertensionmedicationsCaseStudyPatientdetails(renaltransplantation)Number:4438420Sex:MaleWeight:63kgHigh:160cmDateofBirth:1943/02/09Age:63yearsDisease:ChronicnephritisOperationdate:2006/04/19CadavericColdischemiatime(hours):12Heatischemiatime(minutes):5CurrentmedicationImmunosuppressiveregimentsCyclosporine100mgBid125mgBidALG250mgQDMizoribine100mgQD,50mgQNMycophenolatemofetil750mgBidMethylprednisolone500mgQd3dPrednisolone30mgQdCurrentanti-hypertensivemedicationsMetoprolol12.5mgQ12hNifedipineControlledreleased30mgqd30mgQ12hEnalapril10mgQ12hFurosemide40mgtid40mgqdProfilesofbloodpressure05010015020012345678910111213DateBloodpressure(mmHg)systolicdiastolic患者医师药剂师护士MedicalCareNursingCareDrugInformation＆PharmaceuticalCareInformationDrugInformation＆PharmaceuticalCareInformation以患者为中心、以人为本PharmaceuticalCarePharmaceuticalcareandpatientassessmentInitiaterelationshipwithpatientGatherpatientinformation(subjectiveandobjective)Assessinformation(patientassess)CompletetheinterventionDeveloppharmaceuticalcareplanImplementfollow-upGraftandpatientsurvivalKaplan–MeieranalyseswiththepopulationdividedintoquintilesofsystolicBPTutoneVK,etal.ClinTransplant2005:19:181–192.GraftandpatientsurvivalKaplan–MeieranalyseswiththepopulationdividedintoquintilesofdiastolicBPTutoneVK,etal.ClinTransplant2005:19:181–192.Summaryofanti-hypertensiveswithpatientandgraftoutcomesBB,beta-blocker;CC,calciumchannelblocker;Loop,loopdiuretic;ACEI,angiotensinconvertingenzymeinhibitor;ARB,angiotensinreceptorantagonistDiagnosisandtreatmentofhypertensionintherenaltransplantrecipientContinueanti-hypertensivetherapyReassessperiodicallyAdministeranti-hypertensiveAgent(CA,ACEI,orotherBloodpressure=140/90StableGFR?InterventionfailstonormalizeBPConsidersaltrestrictionand/ordiureticMultidrugregimen;addagentsofdifferentclassesasnecessaryReducedoseofcyclosporineortacrolimusEvaluateallograftfunctionOptimalbloodlevelsofcyclosporineortacrolimusECGvolumestatusacceptable?Adequateresponsetotherapy?AcceptableADR?Adequateresponsetotherapy?Re-evaluateallograftfunctionanddrugtherapyConsiderTRASNoYesYesYesNoNoNoNoYesYesYesFrequencyofhypertension60-85%renaltransplantrecipients90%renaltransplantrecipientsadministratedCsACauseofhypertension免疫抑制剂的使用移植肾相关的因素急、慢性排斥反应慢性移植肾病肾动脉狭窄,复发性或新发性肾病,药物肾毒性,尿路梗阻原肾高肾素潴留红细胞增多症RiskFactor免疫抑制剂的升压移植肾功能受损移植肾动脉狭窄RTRs的平均动脉压每升高10mmHg,其移植肾脏功能衰竭的发生率上升30%肾移植后合并血压升高者急性排斥反应发生率远远高于血压降低者尸体肾移植较活体肾移植发生率高DiagnosishypertensionBloodpressurereadingsconsistentlyover140/90mmHgAssessmentofallograftfunction,extracellularfluidvolume(ECF)status,andimmunosuppressivedosingIfthesevariablesarestable,itisreasonabletoproceedwithantihypertensivetherapyTreatmenthypertension130/85mmHgforrenaltransplantrecipientswithoutproteinuria125/75mmHgforproteinuricpatientsTreatmenthypertensionDrugModificationoftheimmunosuppressivetherapyCalciumchannelblockACEinhibitorARBTreatmenthypertensionnondrugAvoidanceofanincreaseinbodyweightSaltrestrictionExerciseSurgeryAnti-hypertensivemedicationsintherenaltransplantrecipientCalciumantagonists(CA)areeffectiveagentsandmayoffertheaddedbenefitofattenuatingcyclosporineinducedchangesinrenalhemodynamics.Verapamil,diltiazem,nicardipine,andmibefradilincreasebloodlevelsofcyclosporineandtacrolimusandshouldbeusedwithcaution.ACEIandARBarealsoeffective;theiruserequiresclosemonitoringofrenalfunction,serumpotassiumlevels,andhematocritlevelsDiureticsfrequentlyareusefuladjunctstotherapyinrecipientsowingtothesaltretentionthatoftenaccompaniescyclosporine参与临床用药工作发现解决潜在的或实际存在的用药问题预防药物治疗中的问题与适应证不符需要其他的药物治疗药物治疗无效药物剂量过低药物治疗中出现的不良反应药物剂量过高顺从性或依从性较差安全合理用药教育医生肾移植患者抗高血压药的使用肾移植患者抗生素的使用护士多巴胺、氯化钾等注射液输注药物浓度、滴注速度患者肾移植患者药物使用可能出现不良反应饮食、出院用药等药学监护PharmaceuticalCare肾移植出现的药物治疗问题确定处理预防姓名性别男种族汉病区—床号24-26病历号4478325身份证号100010194108132533身高170cm体重65kgBMI66kg出生年月1941年8月13日联系电话[phone]手术日期2005/11/23通讯地址北京市海淀区花园北路49号药品不良反应布洛芬消化不良药品过敏史青霉素皮疹家庭药品过敏史不详目前疾病肾脏移植既往病史高血压肾病肾移植类型尸体肾移植吸烟、饮酒和嗜好3只/W；60mL白酒/W；无嗜好目前用药记录开始日期停用日期适应证商品名（药品通用名）药品规格用量、用法临床表现2005/11/232005/12/07器官移植新山地明（环孢素）25mg125mgpoQ12h2005/11/24高血压2005/11/232005/11/25器官移植甲基强的松龙（甲泼尼龙）500mg500mgivQD2005/11/24高血压2005/11/23器官移植骁悉（霉酚酸酯）250mg750mgpoQ12h2005/11/242005/12/03肾功能衰竭、高血压速尿（呋塞米）20mg20mgpoQ12h2005/11/26低血钾，血压未改善2005/11/252005/11/28高血压拜新同（硝苯地平控释片）30mg30mgpoQD2005/11/28血压部分改善2005/11/262005/12/03低血钾缓释钾0.5g0.5gpotid2005/11/29血钾达标2005/11/26器官移植强的松（泼尼松）5mg30mgpoQD2005/11/28高血压拜新同（硝苯地平控释片）30mg60mgpoQD2005/11/28血压部分改善2005/12/01高血压蒙诺(福辛普利)10mg10mgpoQD2005/12/08北京大学第三医院药历肾移植高血压患者监护和随访计划日期疾病状况药物治疗的问题治疗目标目前状况干预措施随访计划2005/11/25高血压血压未控制BP135/85mmHg未改善BP160/110mmHg开始服用拜新同30mgpoQD4w每天监测BP2005/11/26高血压速尿造成低血钾K+3.5-5.0mmol/L未改善K+3.2mmol/L服用缓释钾每天检测血钾2005/11/28高血压拜新同剂量低BP135/85mmHg部分改善BP152/92mmHg继续服用拜新同，增加剂量60mgpoQD每天监测BP2005/11/29高血压低血钾需治疗K+3.5-5.0mmol/L稳定K+3.9mmol/L继续服用缓释钾1w后监测血钾2005/11/30肾移植肾功能部分改善，新山地明剂量低Scr130mol/LC0250-350ng/mL肾功能部分改善Scr267mol/LC0198ng/mL增加新山地明剂量150mgpoQ12h1w1w后监测环孢素谷/峰浓度，肝和