<International Circulation>:  In patients with renal insufficiency with a creatinine of around 265umol/L where there are different types of antihypertensive drugs which can be used but not including and ACE inhibitor or an ARB. In patients with a blood pressure that is difficult to bring under control what in your experience is the best way to treat the patient in this situation?

 《国际循环》：当肾功能衰竭患者的肌酐达到265umol/L时，可以选择非ACE抑制剂或ARBs类降压药。若患者的血压得不到有效控制，那您会采用哪种最佳的治疗措施？
    Prof Juliana Chan: In my experience， for these patients you have to really make an effort to check their compliance， especially if they are taking 3 or 4 drugs， that they are following through the orders you are giving them.  Poor blood pressure control may be due to non compliance and many patients are unwilling to tell you that they are not taking their drugs.  In my experience if these patients have mild renal impairment usually the use of an ACE inhibitor and a CCB usually does the job quite well.  I prefer this combination because they are more neutral on lipid and glucose metabolism because if you give high dose diuretics may have side effects such as reduced potassium levels which in turn may worsen glucose and lipid control. This may also precipitate doubts which patients are prone to. But， when patients start to have significant renal impairment then water retention becomes a big issue and I think these patients will benefit from the administration of Lasix (furosemide). Furthermore， we have to restrict the patients salt intake which is easier said than done. If required，  we could also add additional medications to the patients treatment regimen such as alpha or beta-blockers.  Many of these challenging patients are either obese or overweight and maybe low doses of an aldosterone antagonist may also be useful but you must pay close attention to potassium levels especially in those with renal impairment.  All in all obese patients with moderate renal impairment and difficult to control blood pressure requires both pharmacological intervention and lifestyle changes starting with restrictions in salt intake.

    Chan教授：就我的经验，你一定得努力确认这些患者的依从性，特别是当他们同时服用3-4种药物。血压控制不佳可能是因为患者的依从性，而且很多患者不会告诉你他们未遵医嘱用药。按我的临床经验，ACE抑制剂和CCB可以很好地控制中度肾衰竭患者的血压。我喜欢这种2种药物联合用药，因为它们不会影响脂和糖代谢，因为给予高剂量的利尿剂会引起低钾血症，反而干扰血糖和血脂的控制。如果患者的肾功能严重衰竭，钠水潴留是最主要的问题，此时患者需要使用呋塞米利尿。此外，控制患者钠的摄入量总是说起来容易做起来难。有时候我们还会增加额外的药物如α或β-阻断剂。肥胖或是超重的患者可以服用低剂量的醛固酮拮抗剂，但需密切监测血钾水平，特别是肾衰患者。所有中度肾功能不全并且血压控制不佳的肥胖患者在给予药物治疗的同时需要调整生活方式，严格限制盐的摄入。