【摘要】目的分析透析间期体质量增长情况与透析性低血压(intradialytic-hypotension，IDH)的相关性。方法纳入2017 年1 月～2018 年6 月首都医科大学大兴教学医院收治的146 例维持性血液透析(maintenance hemodialysis,MHD)患者，所有患者均行规律性碳酸氢盐透析，3 次/周，收集患者的基线资料、血生化、透析前后体质量、透析前后血压等资料，根据透析过程中是否出现IDH，分为IDH 组(53例)和无IDH 组(93 例)，进行影响IDH 发生的相关因素分析，分析透析间期体质量增长量(interdialysis weight gain,IDWG)、IDWG%与透析前后血压下降值的相关性。结果IDH 组年龄、糖尿病占比、IDWG、IDWG%、透析前收缩压(systolic blood pressure, SBP)、透析前平均动脉压(mean arterial pressure, MAP)、超滤量、超滤率均高于无IDH 组(t=χ2=6.413, 12.23, 6.821, 6.561, 3.123, 10.059, 9.717, P 均＜0.001)，IDH 组透析前白蛋白低于无IDH 组(t=3.852，P＜0.001)；年龄(OR=2.186,95% CI:1.329～3.596, P= 0.002)、透析前SBP(OR=2.232, 95% CI:1.338～3.723, P=0.002)、IDWG(OR=2.815, 95% CI:1.557～5.088, P=0.001)、IDWG% (OR= 3.093, 95% CI:1.671～5.723, P＜0.001)、超滤量(OR=2.109,95% CI:1.216～3.657, P=0.008)、超滤率(OR=2.284,95% CI: 1.375～3.795,P=0.002)是MHD 患者透析过程中发生IDH 的独立危险因素；MHD 患者IDWG、IDWG%与透析前后SBP (r=0.372, 0.379, P 均＜0.001)、舒张压(diastolic blood pressure,DBP) (r=0.381, 0.395, P 均＜0.001)、MAP 下降值均呈正相关(r=0.314,
0.305, P=0.002,0.003)；IDWG% ≥4.1% 者IDH 发生风险高于IDWG% ＜4.1% 者(Log- rank=21.670，P＜0.001)。结论影响MHD 患者透析过程中发生IDH 的因素较多，透析间期体质量增长与IDH 的发生具有相关性，应加强患者透析期间的体质量控制。
【Abstract】Objective To analyze the correlation between interdialytic weight gain and intradialytic hypotension (IDH). Methods A total of 146 patients with maintenance hemodialysis (MHD) admitted to Daxing Teaching Hospital of Capital Medical University from January 2017 to June 2018 were enrolled in this study. All patients underwent regular bicarbonate dialysis (3 times/week). Their baseline data, blood biochemistry, body mass before and after dialysis, and blood pressure before and after dialysis were collected. According to the presence or absence of IDH during dialysis, the patients were divided into IDH group (53 cases) and non-IDH group (93 cases). The analysis of related factors affecting IDH was performed. The correlation between interdialytic weight gain (IDWG), IDWG% and blood pressure reduction before and after dialysis was analyzed. Results Age, prevalence of diabetes, IDWG, IDWG%, systolic blood pressure (SBP) before dialysis, mean arterial pressure (MAP) before dialysis, ultrafiltration volume and ultrafiltration rate in IDH group were higher than those in non-IDH group (t or χ2=6.413, 12.23, 6.821, 6.561, 3.123, 10.059 and 9.717 respectively; P＜0.001). Albumin before dialysis in IDH group was lower than that in non- IDH group (t=3.852, P＜0.001). Age (OR=2.186, 95% CI: 1.329～3.596, P=0.002), SBP before dialysis (OR=2.232, 95% CI:1.338～3.723, P=0.002), IDWG (OR=2.815, 95% CI:1.557～5.088, P=0.001), IDWG% (OR=3.093, 95% CI: 1.671~5.723, P＜0.001), ultrafiltration volume (OR=2.109, 95% CI: 1.216～3.657, P=0.008) and ultrafiltration rate (OR=2.284, 95% CI: 1.375～3.795, P=0.002) were the independent risk factors for IDH during dialysis in MHD patients. IDWG and IDWG% were positively correlated with the reductions of SBP (r=0.372 and 0.379; P＜0.001), DBP (r=0.381 and 0.395; P＜0.001) and MAP (r=0.314 and 0.305; P=0.002 and 0.003) before and after dialysis. The risk of IDH in patients with IDWG% ≥4.1% was higher than that in patients with IDWG% ＜4.1% (log rank test=21.670, P＜0.001). Conclusion There are many factors affecting the occurrence of IDH during dialysis in MHD patients. Interdialytic weight gain is related to the occurrence of IDH. It is necessary to strictly control the interdialytic weight gain.
[1] 宋亦琪,倪丽,陈靖.维持性血液透析患者营养评估及相关进展[J].中国血液净化,2018,17(1):51-53.
[2] 胡丹,吴险峰,涂卫平.血液透析相关性低血压的临床研究进展[J].中国全科医学,2017,4(6):759-762.
[3] Hussein W F , Schiller B . Dialysate sodium and intradialytic hypotension[J]. Seminars in Dialysis, 2017, 30(6):492-500.
[4] 中华医学会.临床技术操作规范:肾脏病学分册[M].人民军医出版社,2009:93-96.
[5] 叶任高,沈清瑞.肾脏病诊断与治疗学.第1版.北京:人民卫生出版社,1994:629.
[6] Mcintyre C W , Salerno F R . Diagnosis and Treatment of Intradialytic Hypotension in Maintenance Hemodialysis Patients[J]. Clinical Journal of the American Society of Nephrology, 2018, 13(3):CJN.11131017.
[7] 杜丽,祖明辉.个体化饮食指导对慢性肾衰竭维持性血液透析患者营养状况、钙磷代谢及血糖管理的影响[J].安徽医药,2018,22(11):2205-2208.
[8] Chou J A , Streja E , Nguyen D V , et al. Intradialytic hypotension, blood pressure changes and mortality risk in incident hemodialysis patients[J]. Nephrology Dialysis Transplantation, 2018, 33(1):149-159.
[9] 王妍,孙雪,裴淑桥.强制性运动疗法预防血液透析患者相关性低血压的效果观察[J].中华现代护理杂志,2017,23(2):220-223.
[10] Van Buren P N , Inrig J K . Special situations: Intradialytic hypertension/chronic hypertension and intradialytic hypotension[J]. Seminars in Dialysis, 2017,30(6):545-552.
[11] 尹丽霞.血液透析过程中患者饮食干预的研究进展[J].中华护理杂志,2019,54(05):786-790.
[12] 曾巧,周红卫.维持性血透患者透析中收缩压变异性及其影响因素的探讨[J].国际泌尿系统杂志,2019,39(1):104-108.
[13] Yu J , Liu Z , Shen B , et al. Intradialytic Hypotension as an Independent Risk Factor for Long-Term Mortality in Maintaining Hemodialysis Patients: A 5-Year Follow-Up Cohort Study[J]. Blood Purification, 2018, 45(4):320-326.
[14] 王欣,曹艳佩,杨晓莉,等.血液透析患者频发性透析中低血压发生情况和影响因素分析[J].中国实用护理杂志,2019,35(8):599-603.
[15] Keren Doenyas‐Barak, Garra N , Beberashvili I , et al. Immersion‐enhanced fluid redistribution can prevent intradialytic hypotension: A prospective, randomized, crossover clinical trial[J]. Hemodialysis International, 2018, 22(3):377-382.
[16] Wong M M , Mccullough K P , Bieber B A , et al. Interdialytic Weight Gain: Trends, Predictors, and Associated Outcomes in the International Dialysis Outcomes and Practice Patterns Study (DOPPS).[J]. American Journal of Kidney Diseases the Official Journal of the National Kidney Foundation, 2017, 69(3):367-379.
[17] Raimann J G , Ficociello L H , Usvyat L A , et al. Effects of dialysate to serum sodium (Na+) alignment in chronic hemodialysis (HD) patients: Retrospective cohort study from a quality improvement project[J]. BMC Nephrology, 2018, 19(1):75.
[18] 池向耿,蔡琪,许敏玲,等.残余肾功能与血液透析相关性低血压的关系[J].中国医师进修杂志,2017,40(2):117-120.
[19] 吴艺青,陶静,华建武,等.维持性血液透析患者高透析间期体重增长与营养状态的关系[J].中国中西医结合肾病杂志,2018,19(5):440-442.
