目的 观察序贯采用持续缓慢低效透析(sustained low effificiency dialysis,SLED)和间歇性血液透析(intermittent hemodialysis,IHD)治疗合并糖尿病的尿毒症患者的疗效，探索更切实可行的血液透析治疗模式。方法 在知情同意的基础上纳入西部战区总医院血液净化中心维持性血液透析大于3个月的糖尿病患者，分为序贯治疗组和常规治疗组。序贯治疗组：每周IHD 2次+SLED 1次；常规治疗组：每周IHD 3次。比较2组患者的血压(透析前、透析2小时和透析后血压)、血压变异性、透析脱水量、脑利尿钠肽(brain natriuretic peptide,BNP)、尿素清除指数(Kt/V)、尿素清除率(urea reduction ratio, URR)等指标有无差异。 结果 序贯治疗组纳入10例患者，常规治疗组纳入24例患者。2组患者透析前收缩压(t=-1.053，P=0.300)、透析前舒张压(t=-1.020，P=0.315)、透析2h收缩压(t=-1.861，P=0.072)、透析2小时舒张压(t=-1.227，P=0.229)、透析后收缩压(t=-1.901，P=0.066)、透析后舒张压(t=-0.945，P=0.354)、透析期间收缩压变异性(t=-1.784，P=0.084)和透析期间舒张压变异性(t=-1.530，P=0.136)比较，差异均无统计学意义；序贯治疗组透析间期(随诊间)收缩压变异性低于常规治疗组(t=-2.166，P=0.038)。序贯治疗组Kt/V(t=2.878,P=0.007)、URR值(t=2.643,P=0.013)高于常规治疗组。 结论 与常规IHD相比，采用SLED和IHD序贯治疗能更好地控制透析间期血压变异，保证血流动力学的稳定，同时也能改善透析充分性。
Objective To observe the efficacy of the sequential therapy of sustained low efficiency dialysis (SLED) and intermittent hemodialysis (IHD) in uremic patients with diabetes mellitus, and to explore better and practical hemodialysis treatment model. Methods Uremic patients with diabetes mellitus who were undergoing maintenance hemodialysis for more than 3 months were enrolled in this study. The patients were divided into sequential group (IHD twice a week and SLED once a week) and conventional group (IHD 3 times a week). Blood pressure, blood pressure variability, dialysis dehydration, BNP, Kt/V and urea reduction ratio (URR) were compared between the two groups. Results There were 10 patients in the sequential group and 24 patients in the conventional group. Systolic blood pressure (SBP) before dialysis (t=-1.053, P=0.300), diastolic blood pressure (DBP) before dialysis (t=-1.020, P=0.315), SBP at 2 hours of dialysis (t= -1.861, P=0.072), DBP at 2 hours of dialysis (t=-1.227, P=0.229), SBP after dialysis (t=-1.901, P= 0.066), DBP after dialysis (t=-0.945, P=0.354), systolic blood pressure standard deviation (SBP_SD) between dialysis (t=-1.784, P=0.084), and DBP_SD between dialysis (t=-1.530, P=0.136) showed no statistical significances between the two groups. The variability of systolic blood pressure during follow up period (SBP_SD before dialysis) was significantly lower in the sequential group than in the conventional group (t=-2.166，P=0.038); Kt/V (t=2.878, P=0.007) and URR (t=2.643, P=0.013) were higher in the sequential group than in the conventional group. Conclusion Compared with conventional IHD, the sequential therapy of SLED and IHD can better control the blood pressure variation between dialysis, ensure the stability of hemodynamics, and improve the adequacy of dialysis.
[1]Marshell MR, Gopler TA, Shaver MJ, et al. Hybrid renal replacement modalities for the critically[J] .Contrib Nephrol. 2001,132:252-257.
[2]王婷立, 刘芳, 张凌, 等. 持续缓慢低效血液透析治疗在糖尿病肾脏疾病合并多器官功能衰竭患者中的应用[J]. 四川大学学报(医学版). 2012, 43(3): 447-450.
[3]常永丽,刘二兵. 持续低效缓慢血液透析与普通血液透析治疗终末期糖尿病肾病的临床疗效比较研究[J]. 实用心脑肺血管病杂志. 2018,26:198-199.
[4]马晓华,周亚男,王荣荣,等. 持续低效缓慢血液透析治疗终末期糖尿病肾病临床观察[J].解放军医药杂志. 2019, 31(4):57-59.
[5]Cheng HT, Xu X, Lim PS, et al. Worldwide Epidemiology of Diabetes-Related End-Stage Renal Disease, 2000-2015[J]. Diabetes Care. 2021, 44(1):89-97.
[6]Koye DN, Magliano DJ, Nelson RG, et al. The Global Epidemiology of Diabetes and Kidney Disease[J]. Adv Chronic Kidney Dis. 2018, 25(2):121-132.
[7]Coritsidis GN. Sustained low efficiency daily dialysis as renal replacement therapy for the critically ill[J]. ICU Director, 2010, 1(4): 210-213.
[8]付平, 张凌. 杂合肾脏替代治疗的临床应用[J]. 中国血液净化. 2011,10(1):7-9.
[9]Fieghen HE, Friedrich JO, Burns KE, et al. The hemodynamic tolerability and feasibility of sustained low effificiency dialysis in the management of critically ill patients with acute kidney injury[J]. BMC Nephrol. 2010,25(11):32．
[10]Phongphitakchai A, Boonsrirat U. Survival and Predictors of Mortality in Acute Kidney Injury Patients Treated with Sustained Low Efficiency Dialysis[J]. Ann Acad Med Singap.?2020,49(5):306-311.
[11]逄秋荣.持续低效缓慢血液透析与普通血液透析在终末期糖尿病肾病患者中的对比[J].中国中医药现代远程教育. 2012,10(23): 102-103.
[12]李洪, 曾丽花, 卢飞杏, 等. 持续缓慢低效血液透析和连续静脉静脉血液滤过的对照研究[J]. 中华肾脏病杂志. 2005, 21(6): 364-366.
[13]肖扬, 王敏, 吴冰, 等. 持续缓慢低效血液透析对透析中顽固性低血压患者稳定性的临床分析[J]. 2021,7(4):28-30.
[14]余谦,尧逢友,戴宏勋. 血压变异性与原发性高血压靶器官损害的研究进展[J].中国循证心血管医学杂志. 2018,10(4):508-510.
[15]Tatasciore A,Zimarino M,Tommasi R,et al. Increased short-term blood pressure variability is associated with early left ventricular systolic dysfunction in newly diagnosed untreated hypertensive patients[J].Journal of Hypertension. 2013, 31(8):1653-1661.
[16]Metoki H, Ohkubo T,Kikuya M, et al. Prognostic significance for stroke of a morning pressor surge and a nocturnal blood pressure decline: the Ohasama study[J]. Hypertension. 2006, 47(2): 149-154.
[17]Cheng Y, Zhang F, Zhu J, et al. Influence of blood pressure variability on the life of arteriovenous fistulae in maintenance hemodialysis patients[J]. Clin Hemorheol Microcirc. 2016,62(2):129-137.
[18]Cheng Y, Li Y, Zhang F, et al. Interdialytic blood pressure variability and the risk of stroke in maintenance hemodialysis patients[J]. Medicine. 2020, 99(29):e21232.
