Antihypertensive Treatment in Patients with End-Stage Renal Disease

Arterial hypertension is a common finding in patients with end stage renal disease (80% patients are hypertensive). Cardiovascular diseases are the main cause of death in haemodialysis. The present study was performed to asses' successful treatment in hypertensive chronic haemodialysis patients by ultra filtration only and ultra filtration combined with medics. We studied 80 hypertensive adult patients who had been on regular haemodialysis treatment for at least 12 months (average duration of 41 months). All subjects were divided in two different antihypertensive treatment groups including 40 subjects each. The first group of patients were treated with trandolapril and ultra filtration, and the second group of patients were only treated with ultra filtration (control group). Blood pressure measurements before and after HD sessions were performed for each patient. Blood pressure control was defined using World Health Organization criteria 140/90 mm Hg. Average systolic blood pressure levels, after haemodialysis, were in the first group of patients 146.33 +/- 9.7 mm Hg, and in the control group 157,86 +/- 10.33 mm Hg. Average diastolic blood pressure was 87.83 +/- 8.11 mm Hg in the first group of patients and, in the control group it was 91.03 +/- 10.67 mm Hg. There were significant differences between systolic blood pressure level in the first group of patients and the control group of patients as well as in diastolic blood pressure (p < 0.05). We conclude that an antihypertensive therapy by trandolapril is more effective than ultra filtration alone in hypertensive patients on chronic haemodialysis.


Introduction
Hypertension is the most important factor of morbidity and mortality in chronic haemodialysis patients, and a risk of getting sick is as great as treatment necessary.In more than  of these patients hypertension is caused by hypervolemia ().Fast arterial blood pressure control can be gained by decreasing of volume of extra cellular liquid during haemodialysis.But,  -  of patients remain hypertensive ().To decrease mortality of dialysed patients, arterial blood pressure control is very important.The first step in hypertension treatment is diet with limited taking of salt (less than  g of NaCl daily) and liquids, homeostasis control by ultra filtration and gaining of appropriate dried weight ().If we do not get appropriate blood pressure control in this way, it is necessary to use antihypertensive.Aim of this study was examination of blood pressure control efficiency only by treatment of ultra filtration and ultra filtration combined with angiotensin-converting-enzyme inhibitor trandolapril.

Subjects and Methods
It was conducted prospective, randomised, open controlled clinic study what means application of Good Clinical Practice -GCP in two months duration.In research were included  hypertensive patients with end stage renal disease, divided in two groups by  patients.In the first group of patients antihypertensive treatments were applied ultra filtration and trandolapril, and in the second group ultra filtration only.The first group of patients were averaged age , +/-,,  males (, ) and  females (, ).They were on chronic dialysis  +/- months in average.The second group of patients were averaged age , +/-,,  males (, ) and  females (, ).They were on chronic dialysis  +/- months in average.Blood pressure was measured in half laying position and values are expressed by exact measured values.Changes on ECG in sense of hypertrophy of left ventricle were compared before and after the treatment.
ECG was recorded in  leads on SCILLER Cardidiovit AT- Switzerland.For ECG evaluation of hypertrophy of left ventricle were used criteria as follow: -Sum of heights of R-wave in I lead and S-wave in III lead is exciding  mm.-R-wave in V or V is exciding  mm.-R-wave in aVL lead is higher than  mm (when the mean electrical axis is horizontal).-R-wave in aVF lead is higher than  mm (when the mean electrical axis is vertical).

Results
The mean value of systolic arterial blood pressure in the group of patients treated with trandolapril + UF was , +/-, mm Hg and in the group treated only with UF was , +/-, mm Hg.Comparison of the mean values of systolic arterial blood pressure in both groups significant difference has been shown (p<,).
The mean value of diastolic arterial blood pressure in the group of patients treated with trandolapril + UF was , +/-, mm Hg and in the group treated only with UF was , +/-, mm Hg.These values were different too (p<,) (Table ).
Changes on ECG that show hypertrophy of left ventricle were found in  patients treated with trandolapril + UF, and in the group treated only with UF in  patients.After  months treatment there was not any change on ECG in this meaning (Table ).can not attain adequate moving of liquid with dialysis, hypertension will be present and we treat it with antihypertensive.After  months of treatment values of systolic and diastolic blood pressure were different in the group treated with trandolapril + UF and in the group treated only with UF.Successful arterial blood pressure control other authors had () by hypertension treatment with trandolapril alone or combined with calcium canals blockators.In blood pressure control trandolapril was more effective in antiproteinuric effects in patients with primary nephropathy.

Discussion
In the group of patients treated with trandolapril + UF hypertrophy of left ventricle was registered in  patients.After treatment with trandolapril + UF, changes on ECG in the meaning of hypertrophy of left ventricle was not changed.It is understandable because the treatment had been conducted for  months and in that short period we can not expect significant morphology reducing of myocardium.Hypertrophy of left ventricle correlates with blood pressure ().In the last few years number of experimental and clinical reports about structural changing of left ventricle during antihypertensive treatment in uremic patients are increasing (ACE inhibitors first of all) (, , , ).Most authors agree that in spite using of medicine and dialysis, hypertrophy of left ventricle remains ().Histology changes in myocardium have an important role, fibrosis first of all and decreasing of capillary density.Chronic anaemia also contributes to high prevalence of hypertrophy of left ventricle ().
Research shows that the thickness of left ventricle wall had been decreased in the patients with end stage renal disease by strong hypervolemia control what is more important than the decreasing of blood pressure.The guide was blood pressure and dimensions of heart.().We should have in mind that the hypertension is the main cause of cardiopathy in uremic patients.Blood pressure control in hypertensive patients leads to regression of hypertrophy of left ventricle ().

Conclusion
Therapy with UF is more effective in decreasing of high arterial blood pressure in patients with ESRD than the UF alone. Abbreviations