摘要
目的采用近红外线吸收在线血容量监测法，同时结合其他常用方法综合判断血液透析（HD）患者的干体重，寻找评估干体重、预防透析相关高血压及低血压发生的量化指标。方法选取维持性血液透析（MHD）患者108例，根据血压情况分为血压稳定组（A组）43例、低血压组（B组）35例和高血压组（C组）35例。在观察期测定入选患者的血红蛋白（Hb）、血清白蛋白，记录透析前、后的血压、心率和体重，并连续监测透析中超滤量、收缩压、舒张压、平均动脉压（MAP）、心率、相对血容量（RBV）及相应的临床症状，共10-12次。同时测定下腔静脉直径（IVCD）、脑钠素（BNP）、心胸比值（CTR）等指标。干预期则根据监测结果，在在线血容量监测的指导下予以适当的临床干预，进而比较干预前后上述指标变化。结果（1）A组患者RBV变化晦线初始呈双指数逐渐下降，之后呈线性下降直至血液透析结束。（2）B组患者RBV变化曲线表现为前2h比较平稳，随后迅速呈线性下降，变化幅度大于A组（P〈0．05），但用超滤量对RBV进行校正后，B组RBV变化与A组差异无统计学意义。当B组患者透析中出现低血压时，其个体间RBV变化差异有统计学意义P〈0．05，变异系数（CV）=0．28]。（3）C组患者RBV变化曲线呈缓慢的线性下降，透析结束时RBV变化幅度小于A组（P〈0．05）。（4）3组患者透析前VCD值（IVCD经体表面积校正后为VCD）均大于健康人，透析后明显下降（P〈0．05），但B组和C组仍大于A组（P〈0．05）。透析后A组患者心胸比正常，B组和C组大于A组（P〈0．05）。3组患者透析前、后脑钠素均大于正常值，但透析后较透析前显著下降（P〈0．05）。（5）在血容量监测指导下经过临床干预，B组患者控制透析间期体重增长，甚至下调干体重，透析结束时RBV变化幅度明显降低，低血压事件发生率随即显著减少（P〈0．05）；当C组患者下调干体重，加强超滤后，透析结束时RBV变化幅度增大，透析前及透析后的MAP较干预前均显著下降（P〈0．05）。结论（1）症状性低血压患者在第4小时RBV变化率大，△RBV下降幅度显著，该变化对透析中低血压的发生有预测意义。（2）下腔静脉直径及心胸比值对调整干体重有一定意义，但BNP仅对容量变化有指导意义。（3）在线血容量监测能有效指导干体重的调整，减少血透中症状性低血压，控制难治性高血压。
Objective To estimate dry weight （DW） and prevent dialysis-related hypotension and hypertension with the on- line monitoring of relative blood volume （RBV） and other judgments. Methods One hundred and eight maintenance hemodialysis patients were assigned to three groups according to their blood pressure： normal blood pressure group （A group, n=43）, hypotension group （B group, n=35） and hypertension group （C group, n=35）. The level of hemoglobin, serum albumin, dialysis adequacy were determined. Systolic blood pressure, diastolic blood pressure, mean arterial pressure, heart rate, ultrafiltration volume, relative blood volume changes and the corresponding clinical symptoms were monitored during hemodialysis in all patients. Each of the patients was continuously monitored of the indicators above for 10- 12 times. At the observing period, the inferior vena cava diameter （IVCD）, brain natriuretic peptide （BNP） and cardiothoracic ratio（CTR） were measured. Then according to the monitoring results, appropriate clinical interventions were given under on-line blood volume monitoring guidance. Results （1）The shape of RBV curve in group A showed double- exponential curve early, then down to the final linear decling ended during hemodialysis. （2）The RBV curve in group B was stable in the former two hours, then rapidly linear declined. RBV changes were significantly higher in group B than group A （P 〈 0.05）, but when clhanges in RBV were plotted against uhrafihration volume, there was no significant difference in the two groups. The level of RBV reduction at which symptomatic hypotension occurred showed considerable inter- individual variability （P 〈 0.05, coefficient of variation=0.28）. （3）The RBV curve in group C slowly linear declined. At the end of dialysis, RBV changes were significantly lower in group C than group A （P 〈 0.05）. （4）The IVCD values in three groups of patients before dialysis were greater than normal, significantly decreased after the dialysis （P 〈 0.05）, but that in group B and group C were still greater than that in group A （P 〈 0.05）. The BNP values were significantly greater in three groups before and after dialysis （P 〈 0.05）, but after dialysis, the values decreased significantly than that before dialysis （/9 〈 0.05）. （5）After appropriate clinical intervention were given under on-line blood volume monitoring in hemodialysis, the patients of group B controlled weight gain, and even cut dry weight, the RBV change significantly decreased at the end of dialysis and significantly reduced the incidence of hypotension events （P 〈 0.05）; When the patients of group C cut dry weight, increased ultrafihration, the RBV change increased, the mean arterial pressure decreased significantly than before （P〈0.05）. Conclusions （1）Hemodialysis patients with symptomatic hypotension show larger RBV decline rate in the forth hour and lager total RBV changes, which provides important information for forecasting the symptomatic hypotension in hemodialysis. （2）IVCD and CTR have certain significance to the adjustment of dry weight, but the BNP has guiding significance to volume change. （3）On- line monitoring of RBV can effectively guide the adjustment of dry weight, reduction of symptomatic hypotension occruence, and controlling of refractory hypertension in hemodialysis.
出处
《中华肾脏病杂志》
CAS
CSCD
北大核心
2014年第2期104-111,共8页
Chinese Journal of Nephrology
关键词
血液透析
低血压
高血压
血量测定
干体重
Hemodialysis
Hypotension
Hypertension
Blood volume determination
Dry weight
