腎移植高血壓患者藥學(xué)監(jiān)護(hù)

腎移植高血壓患者藥學(xué)監(jiān)護(hù)MajorContentsCauseofhypertensionintherenaltransplantationTreatmentofhypertensionintherenaltransplantrecipientAnti-hypertensionmedicationsCase

StudyPatientdetails(renaltransplantation)

Number:4438420Sex:Male

Weight:63kgHigh:160cm

DateofBirth:1943/02/09Age:63years

Disease:Chronicnephritis

Operationdate:

2006/04/19Cadaveric

Coldischemiatime(hours):12

Heatischemiatime(minutes):5CurrentmedicationImmunosuppressiveregimentsCyclosporine100mgBid125mgBidALG250mgQD

Mizoribine100mgQD,50mgQNMycophenolatemofetil750mgBidMethylprednisolone500mgQd3d

Prednisolone30mgQdCurrentanti-hypertensivemedicationsMetoprolol12.5mgQ12hNifedipineControlledreleased30mgqd30mgQ12hEnalapril10mgQ12hFurosemide40mgtid

40mgqd

172/89患者醫(yī)師藥劑師護(hù)士MedicalCareNursingCareDrugInformation＆Pharmaceutical

CareInformationDrugInformation＆Pharmaceutical

CareInformation以患者為中心、以人為本PharmaceuticalCarePharmaceuticalcareandpatientassessmentInitiaterelationshipwithpatient

Gatherpatientinformation(subjectiveandobjective)Assessinformation(patientassess)CompletetheinterventionDeveloppharmaceuticalcareplan

Implementfollow-upGraftandpatientsurvivalKaplan–MeieranalyseswiththepopulationdividedintoquintilesofsystolicBPTutoneVK,etal.ClinTransplant2005:19:181–192.GraftandpatientsurvivalKaplan–Meieranalyseswiththepopulation

dividedintoquintilesofdiastolicBP

TutoneVK,etal.ClinTransplant2005:19:181–192.Summaryofanti-hypertensiveswithpatientandgraftoutcomes

BB,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RiskFactor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DiagnosishypertensionBloodpressurereadingsconsistentlyover140/90mmHgAssessmentofallograftfunction,extracellularfluidvolume(ECF)status,andimmunosuppressivedosingIfthesevariablesarestable,itisreasonabletoproceedwithantihypertensivetherapyTreatmenthypertension130/85mmHgforrenaltransplantrecipientswithoutproteinuria125/75mmHgforproteinuricpatients

Treatmenthypertension

DrugModificationoftheimmunosuppressivetherapyCalciumchannelblockACEinhibitorARBTreatmenthypertension

nondrugAvoidanceofanincreaseinbodyweightSaltrestrictionExerciseSurgeryAnti-hypertensivemedicationsintherenaltransplantrecipientCalciumantagonists(CA)areeffectiveagentsandmayoffertheaddedbenefitofattenuatingcyclosporineinducedchangesinrenalhemodynamics.Verapamil,diltiazem,nicardipine,andmibefradilincreasebloodlevelsofcyclosporineandtacrolimusandshouldbeusedwithcaution.ACEIandARBarealsoeffective;theiruserequiresclosemonitoringofrenalfunction,serumpotassiumlevels,andhematocritlevelsDiureticsfrequentlyareusefuladjunctstotherapyinrecipientsowingtothesaltretentionthatoftenaccompaniescyclosporine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安全合理用藥教育醫(yī)生腎移植患者抗高血壓藥的使用腎移植患者抗生素的使用護(hù)士多巴胺、氯化鉀等注射液輸注藥物濃度、滴注速度患者腎移植患者藥物使用可能出現(xiàn)不良反應(yīng)飲食、出院用藥等

藥學(xué)監(jiān)護(hù)Pharmaceutical

Care腎移植出現(xiàn)的藥物治療問題確定

處理

預(yù)防姓名性別男種族漢病區(qū)—床號24-26病歷號4478325身份證高170cm體重65kgBMI66kg出生年月1941年8月13日聯(lián)系電術(shù)日期2005/11/23通訊地址北京市海淀區(qū)花園北路49號藥品不良反應(yīng)布洛芬

消化不良藥品過敏史青霉素

皮疹家庭藥品過敏史不詳目前疾病腎臟移植既往病史高血壓腎病腎移植類型尸體腎移植吸煙、飲酒和嗜好3只/W；60mL白酒/W；無嗜好

目前用藥記錄開始日期停用日期適應(yīng)證

商品名（藥品通用名）藥品規(guī)格用量、用法臨床表現(xiàn)2005/11/232005/12/07器官移植新山地明（環(huán)孢素）25mg125mgpoQ12h2005/11/24高血壓2005/11/232005/11/25器官移植甲基強(qiáng)的松龍（甲潑尼龍）500mg500mgivQD2005/11/24高血壓2005/11/23器官移植驍悉（霉酚酸酯）250mg750mgpoQ12h2005/11/242005/12/03腎功能衰竭、高血壓速尿（呋塞米）20mg20mgpoQ12h2005/11/26低血鉀，血壓未改善2005/11/252005/11/28

高血壓拜新同（硝苯地平控釋片）30mg30mgpoQD2005/11/28血壓部分改善2005/11/262005/12/03低血鉀緩釋鉀0.5g0.5gpotid2005/11/29血鉀達(dá)標(biāo)2005/11/26器官移植強(qiáng)的松（潑尼松）5mg30mgpoQD2005/11/28高血壓拜新同（硝苯地平控釋片）30mg60mgpoQD2005/11/28血壓部分改善2005/12/01高血壓蒙諾(福辛普利)10mg10mgpoQD2005/12/08北京大學(xué)第三醫(yī)院藥歷

腎移植高血壓患者監(jiān)護(hù)和隨訪計劃日期疾病狀況藥物治療的問題治療目標(biāo)目前狀況干預(yù)措施

隨訪計劃2005/11/25高血壓血壓未控制BP135/85mmHg未改善

BP160/110mmHg開始服用拜新同30mgpoQD

4w每天監(jiān)測BP2005/11/26高血壓速尿造成低血鉀K+

3.5-5.0mmol/L未改善K+3.2