Hypertension Unit. Doce de Octubre Hospital， Madrid-SPAIN

<International Circulation>:  The guidelines for the management of hypertension have recognized that the relevance of renal function on cardiovascular prognosis of hypertensive patients.  So can you discuss a little bit about the treatment of hypertensive patients with CKD?

Prof. Ruilope: Well first of all the CKD is prevalent in people with hypertension.  In general the rule is that the higher the global cardiovascular risk the higher the prevalence because this is a vicious circle.  So when cardiovascular is damaged， kidney is damaged.  When kidney is damaged， cardiovascular is damaged.  There is an interaction between the two so chronic kidney disease is seen as a situation of really high global cardiovascular risk. What we need to do is first control – very well – blood pressure.  This will require combination therapy and for sure in this combination suppression of the system has to be present.  Is it independent of the presence of albuminuria?  Yes and no because there are two reasons for this.  One of them is albuminuria for the kidney while the other is cardiovascular， so suppression has to be present.  All the drugs， I mean calcium antagonists， diuretics usually are the type of therapy we consider in the first position.  Sure everyone will require a statin and we require aspirin once blood pressure is controlled.  The reason for this is that these people with chronic kidney disease seem to be particularly responsive to global protection of cardiovascular disease. 

《国际循环》：高血压处理指南已经证实了高血压患者的心血管预后与肾功能具有相关性。请您谈谈对合并慢性肾病的高血压患者的治疗。

Ruilope教授：首先，高血压患者中的CKD患病率很高。一般而言，总体心血管风险越高，慢性肾病的患病率就越高，因为这是一个恶性循环。所以当心血管受到损伤时，肾脏也会受到损伤。而肾脏受损伤时，心血管也会受到损伤。两者之间具有相互作用，所以慢性肾脏疾病是心血管病风险的高危状态。我们首先要做的就是控制血压。这需要联合治疗。蛋白尿的出现与此是否有关联呢？这个问题的回答包括两点，即蛋白尿到底是肾源性的还是心血管源性的。对所有药物而言，我觉得钙通道阻滞剂和利尿药是我们首先考虑的用药。当然一旦血压得到控制以后，每个人还都需要使用抑制剂和阿司匹林。原因在于慢性肾病患者似乎对心血管疾病的保护措施反应尤为敏锐。

<International Circulation>:  And with the JNC 7， they recognized that microalbumuria and an estimated GFR value of 60ml/minute per 1.73 are major cardiovascular risk factors.  The guidelines consider higher values of serum creatinine or the presence of proteinuria as associated clinical condition.  What about this topic and the use of S creatinine and estimated glomerular filtrate rate?

Prof. Ruilope:  When the serum creatinine is elevated to 2.1mg/dL in men， 1.3mg/dL in women it is very specific and sensitive for the presence of chronic kidney disease and for an increase risk of global cardiovascular risk.  We are assisting to reappraise the value of estimated GFR using the formulas we are using today because finally these formula was created with data obtained from a group of patients with established renal disease so we need probably to reappraise a bit to make an available formulas but in studies in which the general population is increased， elderly， obese， etcetera.  In these situations nowadays the formula does not reflect the reality for example in obesity， in patients who are elderly， in patients who have special cardio diets we must consider that we have overestimated the value of this formula to classify patients.  It is still valid but if you find someone with an estimated GFR below 60 without microalbuminuria or macroalbuminuria then the story is that the risk for this patient is not elevated.  But if they have albuminuria then the risk is elevated for the cardiovascular but in particular for the kids. 

《国际循环》：JNC-7已经认可了微量蛋白尿和肾小球滤过率估计值60 ml/min /1.73 m2是两大心血管危险因素。指南还认为血清肌酐升高或出现蛋白尿与患者的临床状况有关。那么关于血清肌酐和肾小球滤过率的应用方面将会有什么热点话题要讨论呢？

Ruilope教授：当男性血清肌酐升至2.1mg/dL ，女性升至1.3mg/dL时，出现肾脏疾病和心血管风险的特意度和敏感度都非常高。我们通过常用的公式对肾小球滤过率的值进行重新评估，因为这些公式最终是从一群确诊的肾脏疾病患者中得来的，所以我们需要重新评估，以获得一个适合包括老年、肥胖等很多研究人群都能使用的公式。这样，现今的公式可能高估了某些类别患者的状态，比如肥胖患者，老年患者，某些有与心脏相关特殊饮食的患者。如果你发现在没有微量蛋白尿或巨量蛋白尿的情况下，GFR估计值在60以下，那么这个公式就是无效的，患者的风险并没有升高。但是如果出现蛋白尿，那么心血管病风险就增加了，但对儿童则不一定。

<International Circulation>:  Obviously the JNC 8 re the American guidelines， do you think that this will probably change with the JNC 8?  Or should it change?

Prof. Ruilope:  JNC 8 remains a debate.  It is coming out late next spring so I do not know exactly what they are doing but my perception is that JNC 8 will keep the flavor of the epidemiological concept of guidelines that like JNC 7 or the European guidelines in which the consideration of a given patient is contemplated.  In other words， in clinical practice you can not consider an epidemiological concept of the value of treating billions of patients; you have to treat this particular patient.  And this particular patient has requirements that might fit well the concept that billions of patients will obtain good profit by being treated by a given type of drug.

《国际循环》：您认为美国JNC8指南会有那些可能的变化呢？或者说有哪些地方应该改变？

Ruilope教授：JNC8仍然具有争议。由于它将在明年春天出台，所有我也不知道到底会有什么变化。但是我感觉JNC8会像JNC7或欧洲指南一样保留流行病学的观念，这样一些特定的患者能被关注。换句话说，在治疗亿万患者的临床实践中，我们没法考虑流行病学的观念。这些特定的患者可能很适合这种观念，因此会有很多患者能从某种特定的药物治疗中获益

<International Circulation>:  There has been a lot of progress in pharmacologic therapy – or has there been actually a lot of pharmacologic therapy in hypertensive patients with chronic kidney disease.  What is the progress and how are we doing in that area?

Prof. Ruilope:  Well I think no new drugs seem to be available for treating hypertensive patients with chronic kidney disease.  Probably what we have now are fixed combinations in which drugs which we have used three combinations for a while which will facilitate the control.  We need to revisit suppression of renin angiotensin system because probably we may need to implement doses or we might need to combine in particular those patients with albuminuria because many patients on therapy are developing nowadays have renal disease while under suppression because they are treated for years and then they develop renal damage while on suppression and this is a new story and we need to think about it.

《国际循环》：药物治疗上的进展很多，在高血压和慢性肾病方面的治疗药物也很多。您能谈谈这一方面的进展吗？我们目前在这一领域做得怎样？

Ruilope教授：我认为在高血压合并慢性肾病患者的治疗上并没有可用的新药。我们现在有的药物中有一些固定的组合，我们过去常用3中药物联合使用对患者病情进行控制。我们需要重新回顾对肾素-血管紧张素系统的抑制，因为我们需要得到一个固定剂量或几种药物的联合使用，尤其对某些出现蛋白尿的患者。现在有很多患者在治疗的过程中会出现肾脏疾病，因为他