【摘要】目的探讨终末期肾病(end-stage renal disease,ESRD)伴高血压的维持性血液透析 (maintenance hemodialysis,MHD)患者血压变异性(blood pressure variability,BPV)对心血管事件发生的影响。方法2017 年1 月～2018 年1 月间在绍兴市中心医院接受MHD 治疗伴高血压的患者89 例作为MHD 组，同期进行体检的健康志愿者100 例作为正常对照组，对比其BPV 参数[24h 平均收缩压标准差
(24h standard deviation of mean systolic pressure,24hSBP- SD)、24h 平均舒张压标准差(24h standard deviation of mean diastolic blood preassure,24hDBP-SD)]水平的差异。根据随访期内心血管事件发生情况进一步将MHD 组患者分为心血管事件组32 例、无心血管事件组57 例，收集其临床资料并采用单因素、多因素分析方式明确MHD 患者心血管事件发生的影响因素。结果MHD 组患者的
24hSBP- SD、24hDBP- SD 水平分别为(19.341±2.765)mmHg、(10.102±1.758)mmHg，高于正常对照组的(11.852±1.927)mmHg、(6.824±0.892)mmHg(t=21.844、16.401，均P＜0.001)。MHD 患者中，心血管事件组患者的年龄、24hSBP-SD、24hDBP-SD、血红蛋白水平分别为(67.571±8.542)岁、(22.435±3.094)mmHg、(12.042±1.857)mmHg、(107.341±13.284)g/L；无心血管事件组患者的年龄、24hSBP-SD、24hDBP-SD、血红蛋白水平分别为(59.125 ± 7.432) 岁、(18.017 ± 2.385)mmHg、(8.765 ± 0.929)mmHg、(115.092 ±14.745)g/L，差异有统计学意义(t=4.391、7.537、11.179，P=0.008、P＜0.001、P＜0.001)。Logistics 回归分析发现高龄、24hSBP-SD 及24hDBP-SD 水平较高是MHD 患者心血管事件发生的危险因素，Hb 水平较高是心血管事件发生的保护因素，OR 值分别为1.943、2.509、2.741、0.564(P=0.012、0.007、P＜0.001、0.018)。受试者工作特征(ROC)曲线显示，24hSBP-SD 的截断值为20.73mmHg 时，对应的灵敏度、特异度为84.21%、59.38%；24hDBP-SD 的截断值为10.59mmHg 时，对应的灵敏度、特异度分别为71.93%、71.88%。结论终末期肾病伴高血压患者MHD 是可出现BPV 增加，是后续心血管事件发生的危险因素，且早期测定
BPV 参数可能对心血管事件的发生具有一定预测价值。
【Abstract】Objective To investigate the effect of blood pressure variability (BPV) on cardiovascular events in end-stage renal disease (ESRD) patients on maintenance hemodialysis (MHD) and complicated with hypertension. Methods A total of 89 ESRD patients treated with MHD in our hospital from January 2017 to January 2018 were enrolled as the MHD group, and 100 healthy volunteers for physical examination in our hospital during the same period were recruited as the normal control group. The two BPV parameters, standard deviation of 24h mean systolic blood pressure (24hSBP- SD) and 24h mean diastolic blood pressure
(24hDBP-SD), were examined and compared between the two groups. According to the presence or absence of cardiovascular events during the follow-up period, the MHD patients were further divided into cardiovascular event subgroup (n=32) and non-cardiovascular event subgroup (n=57). Clinical data were analyzed by univariate and multivariate regression methods to evaluate the influencing factors for cardiovascular events in MHD patients. Results The 24hSBP- SD and 24hDBP- SD were 19.341 ± 2.765 mmHg and 10.102 ±1.758mmHg respectively in the MHD group, significantly higher than 11.852 ± 1.927mmHg and 6.824 ±
0.892 mmHg respectively in the normal control group (t=21.844 and 16.401, P＜0.001). Age, 24hSBP-SD, 24HDBP-SD and Hb were 67.571±8.542 years, 22.435±3.094mmHg, 12.042±1.857mmHg and 107.341±13.284g/L respectively in the cardiovascular event subgroup, and were 59.125±7.432 years, 18.017±2.385 mmHg, 8.765±0.929mmHg and 115.092±14.745g/L respectively in the non- cardiovascular event subgroup (t=4.391、7.537、11.179、2.464，P=0.008、＜0.001、＜0.001、0.016). Logistic regression analysis found that older age, higher 24HHBP-SD and 24HDBP-SD were the risk factors for cardiovascular events in MHD patients, while higher Hb level was the protective factor for cardiovascular events (OR=1.943, 2.509, 2.741 and 0.564
respectively; P=0.012, 0.007, 0.000 and 0.018 respectively). Receiver operating characteristic (ROC) curve showed that the sensitivity and specificity were 84.21% and 59.38% respectively when the cut- off value of 24h SBP-SD was set at 20.73mmHg; the sensitivity and specificity were 71.93% and 71.88% respectively, when the cut-off value of 24hDBP-SD was set at 10.59 mmHg. Conclusion BPV was increased in end-stage renal disease patients on MHD and complicated with hypertension. Higher BPV was the risk factor for cardiovascular events. BPV parameters measured earlier may be useful for the prediction of cardiovascular events.
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