【摘要】目的探讨袢利尿剂对有残余肾功能的维持性血液透析(maintenance hemodialysis,MHD)患者容量负荷的影响。方法选择有残余肾功能的MHD 患者进行前瞻性研究，给予呋塞米片，在不使用呋塞米片(F0)、呋塞米片100mg/d 1 月后(F100mg)、和呋塞米片200mg/d 1 月后(F200mg)3 个时点，测量血压，检测24h 尿量(24h urine output，24hUO)、尿电解质和血生化等，应用生物电阻抗测量在F0和F200mg2 个时点测定人体成分，包括多余水分(overhydration，OH)和细胞外液(extracellular water，ECW)。重复测量方
差分析不同时点测量指标的变化趋势，简单效应比较不同时点测量指标的差异。结果不同时点之间的居家收缩压和居家舒张压均有显著差异(F 值分别3.239,4.228；P 值分别为0.048，0.020)。随呋塞米片剂量增加24hUO 显著增加(F=4.395，P=0.030)，F200mg时OH 显著低于F0时OH 值(t=-4.321，P=0.049)，F200mg时ECW 显著低于F0时ECW 值(t=-6.912,P=0.015)。结论在有残余肾功能的MHD 患者中使用呋塞米片能增加尿量，改善容量负荷，降低血压。
【Abstract】Objective To explore the effect of loop diuretic on the fluid load of maintenance hemodialysis (MHD) patients with residual renal function. Methods Twenty- five MHD patients with residual renal function were enrolled and given the titration dose of furosemide tablets. 24-hour urine output(24hUO), urine electrolytes, blood biochemical tests and home blood pressure were measured at three time points: before the use of furosemide tablets (furosemide 0, F0), 1 month after 100mg treatment (furosemide 100mg, F100mg) and 1 month after 200mg treatment (furosemide 200mg, F200mg). Bioimpedance analysis (BIA) is used to measure body composition at two time points (F0 and F200mg), including overhydration (OH) and extracellular water
(ECW). Results There were significant differences in home systolic blood pressure [F0: 151.6±17.9, F100mg: 150.8±18.5, F200mg: (146.5±12.3)mmHg, P=0.048] and home diastolic blood pressure [F0: 84.4±8.1, F100mg: 81.9±6.4, F200mg: (81.6± 7.4)mmHg, P=0.020] among three time points. There were significant differences in 24hUO [F0: 626±567, F100mg:689±577, F200mg:759±699ml, P=0.030] between three time points, which showed an increasing trend of urine volume. There were significant differences in both OH [2.47±1.34 vs. (2.15±1.36L), P=0.049] and ECW [16.62±2.67 vs. (16.10±2.89)L, P=0.015] between the two time points of F0 and F200mg. Conclusion The use of furosemide tablets in MHD patients with residual renal function can increase urine volume and improve fluid load and blood pressure.
[1]Ok E, Asci G, Chazot C, et al.Controversies and problems of volume control and hypertension in haemodialysis[J].Lancet, 2016, 388(10041):285-93
[2]Bargman JM, Thorpe KE, Churchill DN, et al.Relative contribution of residual renal function and peritoneal clearance to adequacy of dialysis: a reanalysis of the CANUSA study[J].J Am Soc Nephrol, 2001, 12(10):2158-62
[3]Mathew AT, Fishbane S, Obi Y, et al.Preservation of residual kidney function in hemodialysis patients: reviving an old concept[J].Kidney Int, 2016, 90(2):262-71
[4]Shafi T, Mullangi S, Toth-Manikowski SM, et al.Residual Kidney Function: Implications in the Era of Personalized Medicine[J].Semin Dial, 2017, 30(3):241-5
[5]Bragg-Gresham JL, Fissell RB, Mason NA, et al.Diuretic use,residual renal function,and mortality among hemodialysis patients in the Dialysis Outcomes and Practice Pattern Study (DOPPS)[J].Am J Kidney Dis, 2007, 49(3):426-31
[6]Sarafidis PA, Persu A, Agarwal R, et al.Hypertension in dialysis patients: a consensus document by the European Renal and Cardiovascular Medicine (EURECA-m) working group of the European Renal Association - European Dialysis and Transplant Association (ERA-EDTA) and the Hypertension and the Kidney working group of the European Society of Hypertension (ESH)[J].J Hypertens, 2017, 35(4):657-76
[7]Lemes HP, Araujo S, Nascimento D, et al.Use of small doses of furosemide in chronic kidney disease patients with residual renal function undergoing hemodialysis[J].Clin Exp Nephrol, 2011, 15(4):554-9
[8]van Olden RW, van Meyel JJ, Gerlag PG.Acute and long-term effects of therapy with high-dose furosemide in chronic hemodialysis patients[J].Am J Nephrol, 1992, 12(5):351-6
[9]Medcalf JF, Harris KP, Walls J.Role of diuretics in the preservation of residual renal function in patients on continuous ambulatory peritoneal dialysis[J].Kidney Int, 2001, 59(3):1128-33
[10]Trinh E, Bargman JM.Are Diuretics Underutilized in Dialysis Patients?[J].Semin Dial, 2016, 29(5):338-41
[11]Sibbel S, Walker AG, Colson C, et al.Association of Continuation of Loop Diuretics at Hemodialysis Initiation with Clinical Outcomes[J].Clin J Am Soc Nephrol, 2019, 14(1):95-102
[12]Wabel P, Chamney P, Moissl U, et al.Importance of whole-body bioimpedance spectroscopy for the management of fluid balance[J].Blood Purif, 2009, 27(1):75-80
[13]Wang K, Bansal N.Diuretic use in incident ESKD: Are we out of the loop?[J].Clin J Am Soc Nephrol, 2019, 14(1):13-5
[14]van Olden RW, Guchelaar HJ, Struijk DG, et al.Acute effects of high-dose furosemide on residual renal function in CAPD patients[J].Perit Dial Int, 2003, 23(4):339-47
[15]Peritoneal Dialysis Adequacy Work G.Clinical practice guidelines for peritoneal dialysis adequacy[J]. [J].Am J Kidney Dis, 2006, 48(Suppl 1):98-129
[16]Gallagher KL, Jones JK.Furosemide-induced ototoxicity[J].Ann Intern Med, 1979, 91(5):744-5
[17]Latif W, Karaboyas A, Tong L, et al.Uric acid levels and all-cause and cardiovascular mortality in the hemodialysis population[J].Clin J Am Soc Nephrol, 2011, 6(10):2470-7
