透析患者容量变化及血压变异对长期预后的影响

发布时间：2018-05-31 19:36

本文选题：血液透析 + 腹膜透析　；参考：《北京协和医学院》2014年硕士论文

【摘要】：研究背景血压是影响透析患者预后的重要因素之一,既往的研究多集中于血压绝对值本身,普通人群中越来越多研究发现血压变异也是决定高血压患者全因死亡及心脑血管死亡的独立危险因素。但是透析人群中血压变异与预后的研究较少,目前还没有关于腹透患者长时血压变异与预后相关性的研究,关于血压变异本身的影响因素研究更少。伴随着透析过程的容量变化是维持性血透患者的重要特征之一,容量变化能够影响短时血压变异已有定论,但是尚无研究涉及其对长时血压变异的影响。研究目的 1、探讨维持性血透患者及腹透患者血压长时变异对预后的影响,分析容量变化对血压长时变异的影响； 2、观察维持性血压患者短期容量变化与透析前后外周及中心动脉血压、血管弹性指标关系,分析动脉弹性及脉搏波折返的影响因素； 3、观察维持性血透患者透析前后肾素、血管紧张素系统(RAS)变化,分析影响RAS活化的因素,探讨水钠变化与RAS变化的相关性。研究方法 1.选择北京协和医院99例维持性血透患者及69例患腹膜透析患者作为研究对象。记录99例血透患者2006年全年共计14703次透析的血压、心率、透析前后体重变化,以血压的变异系数(CV=SD/MEAN)作为血压变异指标。查阅69例患者2008年连续6次门诊血压记录,同样以血压变异系数作为血压变异指标。收集患者一般临床资料、生化指标,分别随访83个月及59个月,观察患者预后资料,将死亡作为终点事件,用SPSS18.0统计软件包进行Cox回归分析。 2.入选54例维持性血透患者,透析前后测量中心动脉血压(SphygmoCor, ArtCor), Omron-Colin测量肱—踝动脉脉搏波传播速度(baPWV),放免法测量透析前后血浆肾素活性(PRA)、血管紧张素Ⅱ (Angll)及醛固酮(ALD)水平,观察容量变化与维持性血透患者血压变化、RAS变化及血管弹性变化的相关性,使用SPSS18.0统计软件包进行单因素相关分析和多元回归分析。研究结果 1.两组患者血压与预后关系随访期内41例(41.4%)维持性血透患者死亡,31例(44.9%)腹透患者死亡心脑血管事件是两组患者最主要的死亡原因,分别占61%及54.8%,血透患者以血管事件为主(80.0%),而腹透患者以心衰为主(52.9%)。透前SBP (preSBP)120mmHg是维持性血透患者全因死亡及心脑血管事件死亡的独立危险因素；门诊SBP153mmHg是腹透患者全因死亡及心脑血管事件死亡的独立危险因素。 2.透前血压变异及心率变异是血透患者死亡的独立危险因素血透患者透前血压变异是全因死亡的独立危险因素,透前血压变异包括收缩压变异系数(SBPCV)(HR1.200,95%CI1.046-1.378,P=0.010),舒张压变异系数(DBPCV)(HR1.097,95%CI1.011-1.184, P=0.018)及收缩压变化斜率(HR6.826,95%CI2.239-20.810, P=0.001)。透前收缩压变异系数(DBPCV)(HR1.147,95%CI1.053-1.250, P=0.002)还是心脑血管事件死亡的独立危险因素。透前心率变异增加血透患者全因死亡风险(HR1.174,95%CI1.011-1.363,P=0.036)。腹透患者没有观察到类似现象。多因素回归分析发现收缩压变异系数(SBPCV)与透析中体重减轻的变异成正相关(13=3.291,P=0.008)而与血白蛋白(ALB)成负相关(p=-0.218,P=0.010),舒张压变异系数(DBPCV)与ALB (β=-0.413, P=0.031)成负相关。 3.血透患者透前血压与容量呈正相关,透后血管弹性发生变化维持性血透患者透析间期体重增长(IDWG)与透前外周及中心动脉SBP成正相关。伴随着透析脱水,透析前后外周及中心血压无差异,但是脉搏波折返减少,血管硬度增加,没有观察到这些变化与容量变化绝对值有关。透析相关性高血压与低血压的发生与动脉弹性及脉搏波折返有关,按照透析第3小时与透前SBP差值是否大于10mmHg将54例患者分为透析相关性高血压组及非高血压组,透析相关性高血压组透后压力增强指数(Aix)高于非高血压组(31.6±25.36%vs21.67±11.51%,P=0.000)。透析相关性高血压组透后Aix升高,非高血压组下降,两组透后baPWV均升高但高血压组升高幅度更明显。按透析中最低SBP90mmHg或MAP下降30mmHg将患者分为透析中低血压组(IDH)及非低血压组,观察到前者透后Aix更低(17.21±10.19%vs30.11±8.18%,P=0.000)。 4.部分血透患者透后RAS升高,升高幅度与水钠清除量成正相关透析过程中伴随着水钠的清除,出现PRA、AngⅡ、ALD升高的患者比例分别为47.4%,52.6%和30.6%。其增加幅度与透析中水钠清除量成正相关。但近50%血透患者RAS对脱水无反应。与非高血压组相比,透析相关性高血压组透后AngⅡ更低(92.53±39.09pg/ml vs67.85±13.28pg/ml, P=0.006)。研究结论 1.透前血压变异及心率变异增加维持性血透患者全因死亡及心脑血管死亡风险；透前血压变异与容量变化及血白蛋白相关。没有观察到门诊血压变异与腹透患者死亡的相关性; 2.短期容量变化决定血透患者外周动脉及中心动脉血压,部分血透患者存在伴随水钠清除的RAS活化； 3.透析中血管硬度及阻力变化是导致透析中血压变化的主要原因,但RAS水平与血管硬度变化没有相关性。
[Abstract]:Research background
Blood pressure is one of the important factors affecting the prognosis of dialysis patients. Previous studies are mostly focused on the absolute value of blood pressure itself. More and more studies in the general population have found that blood pressure variation is also an independent risk factor determining all causes of death and cardiovascular death in hypertensive patients. However, there are few studies on blood pressure variation and prognosis in dialysate population. There is no previous study on the correlation between long time blood pressure variability and prognosis in patients with peritoneal dialysis. There is less research on the influence factors of blood pressure variability itself. The effect of blood pressure variation.
research objective
1, to explore the effect of long term blood pressure variability on prognosis in patients with maintenance hemodialysis and peritoneal dialysis, and analyze the effect of volume changes on long term blood pressure variability.
2, the relationship between the changes of the short-term volume of the patients with maintenance blood pressure and the blood pressure of the central artery before and after the dialysis, the relationship between the vascular elasticity index, and the influencing factors of the arterial elasticity and pulse wave reentry were analyzed.
3, to observe the changes of renin and angiotensin system (RAS) before and after dialysis in patients with maintenance hemodialysis, to analyze the factors affecting the activation of RAS, and to explore the correlation between the changes of sodium water and the changes of RAS.
research method
1. in Peking Union Medical College Hospital, 99 patients with maintenance hemodialysis and 69 patients with peritoneal dialysis were selected as subjects. The blood pressure, heart rate, weight change before and after dialysis in 99 cases of hemodialysis were recorded in 99 cases of hemodialysis in 2006, and the variation coefficient of blood pressure (CV=SD/MEAN) was used as the index of blood pressure variation. 69 patients were consulted in 6 consecutive outpatients in 2008. The blood pressure variation was also used as the index of blood pressure variation. The general clinical data and biochemical indexes were collected for 83 months and 59 months respectively. The prognosis of the patients was observed, the death was taken as the end point, and the Cox regression analysis was carried out by the SPSS18.0 software package.
2. patients were enrolled in 54 patients with maintenance hemodialysis. The blood pressure of central artery (SphygmoCor, ArtCor) was measured before and after dialysis. The speed of brachial pulse pulse wave propagation (baPWV) was measured by Omron-Colin. Radioimmunoassay was used to measure the plasma renin activity (PRA), angiotensin II (Angll) and aldosterone (ALD) level before and after dialysis, and the changes of capacity and maintenance hemodialysis patients were observed. The correlation of blood pressure, RAS and vascular elasticity was analyzed by single factor correlation analysis and multiple regression analysis using SPSS18.0 statistical software package.
Research results
The relationship between blood pressure and prognosis in 1. two groups
During the follow-up period, 41 cases (41.4%) died of maintenance hemodialysis patients and 31 (44.9%) patients with peritoneal dialysis were the main causes of death in two groups, accounting for 61% and 54.8% respectively. Hemodialysis patients were mainly vascular events (80%), and the patients with peritoneal dialysis were mainly with heart failure (52.9%). SBP (preSBP) 120mmHg was the death of the patients with maintenance hemodialysis. SBP153mmHg is an independent risk factor for all-cause death and cardiovascular and cerebrovascular events in patients with peritoneal dialysis.
2. pre exposure blood pressure variability and heart rate variability are independent risk factors for mortality in hemodialysis patients.
Pre transmex blood pressure variation is an independent risk factor for all causes of death. Pre transmex blood pressure variation includes systolic pressure variation (SBPCV) (HR1.200,95%CI1.046-1.378, P=0.010), diastolic pressure variation (DBPCV) (HR1.097,95%CI1.011-1.184, P=0.018) and systolic pressure variation slope (HR6.826,95%CI2.239-20.810, P=0.001). Pre transdermal systolic pressure variation The coefficient (DBPCV) (HR1.147,95%CI1.053-1.250, P=0.002) is an independent risk factor for the death of cardio cerebral vascular events. Pre transmex heart rate variability increases the risk of all cause death in hemodialysis patients (HR1.174,95%CI1.011-1.363, P=0.036). No similar phenomenon has been observed in patients with peritoneal dialysis.
The multifactor regression analysis found that the systolic pressure variation coefficient (SBPCV) was positively correlated with the variation of weight loss in dialysis (13=3.291, P=0.008) and was negatively correlated with serum albumin (ALB) (p=-0.218, P=0.010), and the diastolic pressure variation coefficient (DBPCV) was negatively correlated with ALB (beta =-0.413, P= 0.031).
3. there was a positive correlation between blood pressure and volume before hemodialysis.
The interdialysis interval weight growth (IDWG) was positively related to the pre transdialysis and central artery SBP formation in the patients with maintenance hemodialysis. With dialysis dehydration, there was no difference in the peripheral and central blood pressure before and after dialysis, but the pulse wave reentry decreased and the blood vessel hardness increased, and no observation was made of the changes in the absolute value of the volume change.
The incidence of hypertension and hypotension in dialysis related hypertension was related to arterial elasticity and pulse wave reentry. 54 patients were divided into dialysis related hypertension group and non hypertensive group according to whether the difference between third hours and pre transdialysis SBP difference was greater than 10mmHg. The post dialysis pressure enhancement index (Aix) was higher than that of non hypertensive group (31.6 + 25.36%). Vs21.67 + 11.51%, P=0.000). After dialysis related hypertension, Aix increased and non hypertensive group decreased. The two groups increased baPWV after dialysis, but the increase in hypertension group was more obvious. According to the lowest SBP90mmHg or MAP drop in dialysis, the patients were divided into dialysate hypotension group (IDH) and non hypotension group, and the former was lower (17.21 + 10.) after dialysis (17.21 + 10.). 19%vs30.11 + 8.18%, P=0.000).
The 4. part is the increase of RAS in patients after hemodialysis, and the increase is positively correlated with the amount of water and sodium clearance.
With the removal of sodium water during dialysis, the proportion of patients with PRA, Ang II, and ALD increased, respectively, was 47.4%, 52.6% and 30.6%. were positively correlated with the sodium water removal in dialysis. But in nearly 50% hemodialysis patients, RAS did not respond to dehydration. Compared with the non hypertensive group, Ang II was lower in the dialysis related hypertension group (92.53 + 39.09pg/ml VS). 67.85 + 13.28pg/ml, P=0.006).
research conclusion
Blood pressure variation and heart rate variability increased the risk of death and cardiac and cerebrovascular death in patients with maintenance hemodialysis; pre transmence blood pressure variation was associated with volume change and serum albumin. No correlation between blood pressure variation and death of patients with peritoneal dialysis was observed.
2. the change of short-term capacity determines the blood pressure of peripheral artery and central artery in hemodialysis patients, and RAS activation in patients with partial hemodialysis is accompanied by sodium and sodium clearance.
3. changes in vascular stiffness and resistance during dialysis are the main causes of blood pressure changes during dialysis, but there is no correlation between RAS level and vascular stiffness changes.
【学位授予单位】：北京协和医学院
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：R692.5

【参考文献】