【摘要】目的了解维持性血液透析(maintenance hemodialysis,MHD)患者透析期间血压的波动特点，并探究其与容量的关系。方法选取2017 年12月～2018年6月间在杭州市中医院血液净化中心收治的231 例MHD 患者，根据透析期间收缩压(systolic blood pressure, SBP)情况分为血压升高组(△SBP≥10mmHg)、血压稳定(-20mmHg＜△SBP＜10mmHg)和血压下降组(△SBP≤-20mmHg)。应用生物电阻抗法测得MHD 患者透析前后水负荷值(overhydration,OH)、细胞内液(intracellular water,ICW)、细胞外液(extracellular water, ECW)、总体水量(total body water，TBW)等容量指标，同时收集患者一般临床资料以及实验室指标。结果①血压升高组患者43 例, 血压稳定组患者119 例, 血压下降组患者69 例。血压升高组患者在透析结束后SBP 达到高峰；而血压下降组患者血压在透析3h 处于最低水平，随后略有上升。②血压升高组超滤量较血压稳定组低(t=3.861,P＜0.001)，而血压下降组超滤量较血压稳定组高(t=3.885, P＜0.001)。③相对于血压稳定组，血压升高组透析后OH 值、透析后ECW/TBW 较高(t 值分别为2.386,2.317；P 值分别为0.018, 0.021)。进一步的受试者工作曲线分析发现，透析后OH 值、ECW/TBW 判断血压升高的曲线下面积分别为0.621(95% CI:0.546～0.697,P=0.004)、0.604(95% CI:0.526～0.682,P=0.012)。结论MHD 患者血压不稳定的现象较为常见。血压下降组患者血压多在透析第3 小时降到最低，与超滤量有关。而血压升高组患者血压多在透析后达到高峰，且存在慢性的容量负荷的趋势，尤以细胞外液为主。
【Abstract】Objective To analyze the characteristics of blood pressure fluctuation during hemodialysis sessions in maintenance hemodialysis (MHD) patients, and to explore the correlation with volume load. Methods A total of 231 MHD patients admitted to the blood purification center of Hangzhou Traditional Chinese Medicine Hospital from December 2017 to June 2018 were enrolled in this study. According to the blood pressure variation during dialysis sessions, they were divided into hypertension group (△SBP ≥10mmHg), stable group (-20mmHg＜ △SBP ＜10mmHg) and hypotension group (△SBP ≤-20mmHg). The volume indicators of overhydration (OH), intracellular water (ICW), extracellular water (ECW) and total body water (TBW) were measured before and after the sessions by using bioelectrical impedance. General clinical data and laboratory indicators were also recorded. Results ①There were 43 patients (19%) in the hypertension group, 119 patients (51%) in the stable group, and 69 patients (30%) in the hypotension group. In the hypertension group, blood pressure reached the peak after the end of dialysis sessions. In the hypotension group, blood pressure was at the lowest level in the third hour in dialysis sessions, followed by a slight increase. ②Compared with the stable group, ultrafiltration volume was lower in the hypertension group (t=3.861, P＜0.001), and was higher in the hypotension group (t=3.885, P＜0.001). ③ Compared with the stable group, post-dialytic OH and ECW/TBW were higher in the hypertension group (t=2.386, P=0.018; t=2.317, P=0.021). ROC analysis showed that the area under the curves of post-dialytic OH and ECW/TBW to determine hypertension were 0.621 (95% CI: 0.546～0.697, P=0.004) and 0.604 (95% CI: 0.526～0.682, P=0.012) respectively. Conclusion Unstable blood pressure during hemodialysis sessions was frequently seen in MHD patients. In the hy-potension group, blood pressure reduced to the lowest in the third hour in dialysis sessions, suggesting that ultrafiltration volume is related to the hypotension. In the hypertension group, blood pressure reached a peak after dialysis, suggesting the presence of chronic volume overload, especially the extracellular water overload.
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