目的 应用心率变异性(heart rate variability,HRV)及皮肤交感神经活性(skin sympathetic nerve activity,SKNA)的方法，探讨持续非卧床腹膜透析(continuous ambulatory peritoneal dialysis,CAPD)与维持性血液透析(maintenance hemodialysis,MHD)患者在单次透析过程中自主神经张力变化及差异。 方法 纳入2021年2月─7月在南京医科大学第一附属医院肾科住院的CAPD患者及血液透析中心MHD患者，自透析开始(MHD患者自48h间隔后上机，CAPD患者晨起时更换夜间留腹透析液)采集4 h连续高频心电信号，依据透析方式不同分为CAPD组及MHD组，并比较2组患者透析中每30 min平均心率、全部正常窦性心搏间期的标准差(standard deviation of the interbeat interval of normal sinus beats,SDNN)、标准化低频功率(normalized low frequency power,LFn)、标准化高频功率(normalized high frequency power,HFn)、低频高频功率比值(LF/HF)及SKNA平均电压(average voltage of SKNA，aSKNA)的变化及组间差异。 结果 共纳入30例CAPD及50例MHD患者。2组患者第1、2个30 min的平均心率(t=-2.210、-2.426,P=0.037,0.018)及HFn(Z=2.226、2.027，P=0.026、0.043)有统计学差异，第2个30 min的LFn有统计学差异(t=-2.548,P=0.013)。透析后，2组患者均表现出LF/HF升高(Z=3.162,2.980,P=0.011,0.020)，MHD组变化更早；MHD组平均心率增加(q=3.336,P=0.009)，HFn降低(Z=4.123,P＜0.001)。各时段aSKNA 2组相比无统计学差异(0.010＜|Z|＜1.109,均P＞0.05)，但MHD组动态变化更大(Z ＞3.125,P＜0.05)。 结论 MHD患者较CAPD患者在单次透析中自主神经指标变化更大。
Objective To observe the changes of autonomic nervous tone in continuous ambulatory peritoneal dialysis (CAPD) and maintenance hemodialysis (MHD) patients during a single dialysis process using heart rate variability (HRV) and skin sympathetic nerve activity (SKNA). Methods From February 2021 to July 2021, CAPD patients and MHD patients from the First Affiliated Hospital of Nanjing Medical University were enrolled. These patients were assigned into two groups: CAPD group and MHD group. High-frequency ECG signals were collected for 4 consecutive hours from the beginning of a single dialysis session. After signal processing, HRV and SKNA were analyzed, and then the average values of each 30 minutes were calculated, respectively. The average voltage of SKNA (aSKNA) and HRV indexes were compared between the two groups. Results A total of 30 CAPD patients and 50 MHD patients were included. The mean heart rate and normalized high frequency power (HFn) of 0-30 minutes and 30-60 minutes were different between the two groups (t=-2.210, -2.426, Z=2.226, 2.027, P=0.037, 0.018, 0.026, 0.043), the normalized low frequency power (LFn) of 30-60 minutes was also different (t=-2.548, P=0.013). After dialysis, low frequency power to high frequency power ratio (LF/HF) increased in both groups (Z=3.162, 2.980, P=0.011, 0.020), while changes happened earlier in the MHD group. The mean heart rate increased (q=3.336, P=0.009) and HFn decreased (Z=4.123, P＜0.001) significantly in MHD group. There was no significant difference in aSKNA between two groups (0.010＜|Z|＜1.109, all P＞0.05), but MHD group showed a greater dynamic change (Z＞3.125, P＜0.05). Conclusion During a single dialysis session, MHD patients showed a greater change in autonomic system tone compared with CAPD patients.
[1] Wanner C, Amann K, Shoji T. The heart and vascular system in dialysis[J]. LANCET,2016,388(10041):276-84.
[2] Ahmadmehrabi S, Tang W H W. Hemodialysis‐induced cardiovascular disease[J]. Seminars in Dialysis, 2018,31(3):258-267.
[3] Wong B, Ravani P, Oliver MJ, et al. Comparison of Patient Survival Between Hemodialysis and Peritoneal Dialysis Among Patients Eligible for Both Modalities[J]. Am J Kidney Dis,2018,71(3):344-351.
[4] Salman I M. Cardiovascular Autonomic Dysfunction in Chronic Kidney Disease: a Comprehensive Review[J]. Current Hypertension Reports, 2015,17(8).
[5]Quarti-Trevano F, Seravalle G, Dell Oro R, et al. Autonomic Cardiovascular Alterations in Chronic Kidney Disease: Effects of Dialysis, Kidney Transplantation, and Renal Denervation[J]. Current Hypertension Reports, 2021,23(2).
[6] Yang L, Zhao Y, Qiao B, et al. Heart Rate Variability and Prognosis in Hemodialysis Patients: A Meta-Analysis[J]. Blood Purif,2021,50(3):298-308.
[7] Chang Y, Shiao C, Chang K, et al. Heart rate variability is an indicator for intradialytic hypotension among chronic hemodialysis patients[J]. Clinical and Experimental Nephrology, 2016,20(4):650-659.
[8] Kusayama T, Wong J, Liu X, et al. Simultaneous noninvasive recording of electrocardiogram and skin sympathetic nerve activity (neuECG)[J]. Nat Protoc,2020,15(5):1853-1877.
[9] Jiang Z, Zhao Y, Doytchinova A, et al. Using skin sympathetic nerve activity to estimate stellate ganglion nerve activity in dogs[J]. Heart Rhythm,2015,12(6):1324-1332.
[10] Kutkut I, Uceda D, Kumar A, et al. Skin sympathetic nerve activity as a biomarker for neurologic recovery during therapeutic hypothermia for cardiac arrest[J]. Heart Rhythm, 2021,18(7):1162-1170.
[11] Wang W, Cheng H, Zhang Y, et al. Skin sympathetic nerve activity as a biomarker for outcomes in spontaneous intracerebral hemorrhage[J]. Ann Clin Transl Neurol, 2023,10(7):1136-1145.
[12] Zhang Y, Wang J, Xing Y, et al. Dynamics of Cardiac Autonomic Responses During Hemodialysis Measured by Heart Rate Variability and Skin Sympathetic Nerve Activity: The Impact of Interdialytic Weight Gain[J]. Frontiers in Physiology, 2022,13.
[13] Xing Y, Zhang Y, Yang C, et al. Design and evaluation of an autonomic nerve monitoring system based on skin sympathetic nerve activity[J]. Biomed Signal Proces,2022,76:103681.
[14] Vest AN, Da Poian G, Li Q, et al. An open source benchmarked toolbox for cardiovascular waveform and interval analysis.[J]. Physiol Meas,2018:39,105004.
[15] 中华心血管病杂志编委会心率变异性对策专题组. 心率变异性检测临床应用的建议[J]. 中华心血管病杂志,1998,26(4).
[16] Shaffer F, Ginsberg JP. An Overview of Heart Rate Variability Metrics and Norms[J]. Front Public Health,2017,5.
[17] Zhang L, Zhao M, Zuo L, et al. China Kidney Disease Network (CK-NET) 2016 Annual Data Report.[J]. Kidney Int Suppl (2011). 2020;10(2):e97-e185.
[18] Jung H, Choi H, Choi J, et al. Dialysis modality-related disparities in sudden cardiac death: hemodialysis versus peritoneal dialysis[J]. Kidney Res Clin Pract,2019,38(4):490-498.
[19] Roy-Chaudhury P, Tumlin JA, Koplan BA, et al. Primary outcomes of the Monitoring in Dialysis Study indicate that clinically significant arrhythmias are common in hemodialysis patients and related to dialytic cycle[J]. Kidney Int,2018,93(4):941-951.
[20] Fukuta H, Hayano J, Ishihara S, et al. Prognostic value of nonlinear heart rate dynamics in hemodialysis patients with coronary artery disease[J]. Kidney Int,2003,64(2):641-648.
[21] Suzuki M, Hiroshi T, Aoyama T, et al. Nonlinear Measures of Heart Rate Variability and Mortality Risk in Hemodialysis Patients[J]. Clin J Am Soc Nephrol,2012,7(9):1454-1460.
[22] Laaksonen S, Voipio-Pulkki L, Erkinjuntti M, et al. Does dialysis therapy improve autonomic and peripheral nervous system abnormalities in chronic uraemia?[J]. J Intern Med,2000,248(1):21-26.
[23] Giordano M, Manzella D, Paolisso G, et al. Differences in heart rate variability parameters during the post-dialytic period in type II diabetic and non-diabetic ESRD patients[J]. Nephrol Dial Transplant,2001,16(3):566-573.
[24] Tong Y, Hou H. Alteration of Heart Rate Variability Parameters in Nondiabetic Hemodialysis Patients[J]. Am J Nephrol,2007,27(1):63-69.
[25] Doytchinova A, Hassel J L, Yuan Y, et al. Simultaneous noninvasive recording of skin sympathetic nerve activity and electrocardiogram[J]. Heart Rhythm, 2017,14(1):25-33.
[26] Kim J E, Choi Y J, Hwang S, et al. Target blood pressure in Korean hemodialysis patients for optimal survival[J]. Kidney research and clinical practice, 2023.
