Percobaan Acak Diuretik Distal versus Pembatasan Natrium Diet untukHipertensi pada PenyakitGinjal

Kronis
Bovée DM, Visser WJ, Middel I, De Mik-van Egmond A, Greupink R, Masereeuw R, Russel
FGM, Danser AHJ, Zietse R, Hoorn EJ. A Randomized Trial of Distal Diuretics versus Dietary
Sodium Restriction for Hypertension in Chronic Kidney Disease. J Am Soc Nephrol. 2020
Mar;31(3):650-662. doi: 10.1681/ASN.2019090905. Epub 2020 Jan 29. PMID: 31996411;
PMCID: PMC7062227.

ABSTRAK
Latar Belakang
Diuretik distal dianggapkurangefektifdibandingkandiuretik loop pada CKD. Namun, data
untukmendukungpersepsiiniterbatas.
Metode
Untukmenyelidikiapakahdiuretik distal lebihrendahdaripadapembatasan natrium diet
dalammengurangitekanandarah pada pasiendengan CKD stadium G3 atau G4 dan hipertensi, kami
melakukan uji cobasilang label terbukaselama 6 minggu yang membandingkanamilorida/hidroklorotiazid
(5 mg/50 mg setiaphari ) denganpembatasan diet natrium (60 mmol per hari). Obat
antihipertensidihentikanselama 2 minggusebelumpengacakan. Kami menganalisisefek pada
tekanandarah, fungsiginjal, dan keseimbangancairan dan
menghubungkannyadenganpembersihandiuretikginjal.
Hasil
Sebanyak 26 pasien (dengan rata-rata eGFR 39 ml/menit per 1,73 m2) menyelesaikankeduaperawatan.
Pembatasan natrium diet mengurangiekskresi natrium dari 160 menjadi 64 mmol per hari. Diuretik yang
dihasilkanpengurangan yang lebihbesar pada tekanandarahsistolik 24 jam (SBP; dari 138 menjadi 124
mmHg) dibandingkandenganpembatasan natrium (dari 134 menjadi 129 mm Hg), sertaefek yang
lebihbesarsecarasignifikan pada air ekstraseluler, eGFR, renin plasma, dan aldosteron.
Keduaintervensimenghasilkanpenurunanberat badan dan NT-proBNP yang serupa.
Keduapendekatantersebuttidakmenurunkan albuminuria secarasignifikan,
sedangkandiuretiksecarasignifikanmengurangiekskresi angiotensinogen dan b2-mikroglobulin urin.
Meskipun eGFR yang lebihrendah dan indoksilsulfat plasma yang
lebihtinggiberkorelasidenganpembersihandiuretik yang lebihrendah, efekdiuretik pada berat badan dan
tekanandarah pada eGFR yang lebihrendahdipertahankan. Selama pengobatandiuretik, ekskresi PGE2
yang lebihtinggiberkorelasidenganpembersihan air bebas yang lebihrendah, dan
empatpasienmengalamihiponatremiaringan.
Kesimpulan
Diuretik distal tidakkalahdenganrestriksi natrium diet dalammenurunkantekanandarah dan volume
ekstraseluler pada CKD. Sensitivitasdiuretik pada CKD
dipertahankanmeskipunpembersihandiuretiklebihrendah.
Comparison Between Distal Diuretics and Dietary Sodium Restriction for Hypertension in
Chronic Kidney Disease : A Systemic Review

Shinta Retno Wulandari1, Asticha Erlianing Sari1

1
Faculty of Medicine Sebelas Maret University, Central Java, Indonesia

Objectives : Chronic kidney disease (CKD) is characterized by salt – sensitive hypertension and
overhydration. It is unknown whether dietary or pharmacologic approaches are preferable to
reduce sodium in CKD. This systematic review evaluates the effect of distal diuretics and dietary
sodium restriction on hypertension in CKD.
Methods : We did a comprehensive searching on distal diuretics and dietary sodium restriction
for hypertension in CKD published in 2016 - June 2021 through Pubmed and Cochrane Library.
We found 19 studies and two eligible studies were included in this study. Risk of bias analysis
was performed using the Cochrane Risk of Bias.
Results : Twenty-six patients with CKD stage 3 or 4 and hypertension were included in this
study (baseline eGFR 39 ± 13 ml/min/1.73 m 2). We compared dietary Na+ restriction (60
mmol/day) versus amiloride/hydrochlorothiazide (5/50 mg once daily). Both interventions lasted
for two weeks and were separated by a 2-week wash-out period.  Urinary Na+ excretion was
successfully lowered with dietary Na+ restriction (160 ± 66 to 64 ± 37 mmol/day, p < 0.01), and
remained similar with diuretics (154 ± 47 to 153 ± 63 mmol/day, p = 0.95). Dietary
Na+ restriction lowered 24-hour SBP (134 ± 12 to 129 ± 14 mmHg , p < 0.05), while diuretics
had a greater effect (138 ± 12 to 124 ± 13 mmHg, p < 0.01 for within and between
interventions). Both maneuvers significantly lowered indices of fluid overload, including body
weight, NT-pro-BNP (median -10 and -7 pmol/L) and overhydration as assessed by
bioimpedance (-0.6 ± 0.6 and -1.3 ± 0.7 L).
Conclusions Diuretics produce greater effects than dietary Na + restriction. Distal diuretics and
dietary Na+ restriction effectively lower blood pressure in CKD 3 and 4 in the absence of renin-
angiotensin inhibitors. Both interventions also lower indices of fluid overload.
 Records identified through Pubmed Additional records identified through Cochrane
n = 11 n = 14

Records excluded (n =
not English
Records screened not RCT
n = 25 not 10 years prior
 
Exclusion criteria:
serum creatinine more than 2
acute myocardial infarction,
congestive heart failure,
Full-text articles assessed for eligibility unstable coronary syndrome,
n = 14 cardiogenic shock,
history of end-stage renal fail
on dialysis,
N-acetyl cysteine use
hemodynamic instability dur
the procedure, known allergy
administration of pentoxifyllin
use of concomitant nephrot
(e.g. non-steroidal anti-in
drugs, aminoglycosides, rec
injection, etc.) and diuretics
 
Studies included in narrative synthesis  
n=2