干体质量调整对维持性血液透析患者合并肺动脉高压的影响

目的 观察维持性血透患者合并肺动脉高压时通过干体质量的调整对肺动脉高压的影响.方法 观察2012年3月至2013年4月在湖北医药学院附属太和医院肾病内科维持性透析120例患者中18例合并肺动脉高压患者,透析龄均超过1年,平均透析年龄3.41±1.23年,其中男性12例,女性6例,平均年龄47.44±6.13岁.病因慢性肾小球肾炎10例,糖尿病肾病5例,高血压良性小动脉肾硬化症2例,肾结核1例.所有患者均行常规血液透析,每周透析3次,使用聚砚膜1.4m2透析器.所有患者均行超声心动图检测肺动脉收缩压（PASP）≥35mmHg,确诊肺动脉高压后,观察治疗前患者血压、血红蛋白、血磷、甲状旁腺激素、血浆脑钠肽、利用超声心动图检测右房横径、右房长径、肺动脉内径、肺动脉收缩压,通过下调干体质量1月后再次复查上述指标. 结果 通过下调干体质量后,所有患者治疗后肺动脉压力为42.00±6.75mmHg较治疗前48.00±8.15mmHg明显下降,有显著意义（P＜0.05）,血浆脑钠肽浓度由治疗前7467.8±2357.4 pg/ml下降至4759.2±1367.9 pg/ml,治疗后,右房横径（26.84±4.23mm）、右房长径（35.96±8.69mm）、肺动脉内径（21.64±2.49mm）较治疗前（32.19±7.93mm、43.09±8.95mm、25.18±4.06mm）缩小,有显著统计学意义.左心室内径（50.25±5.39mm）较治疗前（56.15±6.28mm）明显缩小,左心室射血分数（55.3±13.6％）较治疗前（43.2±12.3％）明显升高,有显著统计学意义（P＜0.05）.下调干体质量后对患者血压、血红蛋白、血甲状旁腺激素、血钙浓度、血磷浓度与治疗前比较无显著统计学意义（P＞0.05）.结论维持性血液透析患者合并肺动脉高压可通过下调干体重,清除体内过多水分,缩小右心房横径及肺动脉内径,降低肺动脉压力.缩小右心室内径,减轻对左心室挤压,缩小左心室内径,增加左心室射血分数,明显改善左心室收缩功能.

The effect of dry weight adjustment on the pulmonary hypertension in maintenance hemodialysis patients

Objective To investigate the effect of dry body weight adjustment on the pulmonary hypertension in maintenance hemodialysis （MHD） patients.Methods In the 120 uremic patients treated with MHD in our hospital in the period from March,2012 to April,2013,pulmonary hypertension was found in 18 cases.They had the dialysis age of more than one year （3.41±1.23 years）,12 were males and 6 were females,and the average age was 47.44±6.13 years old.The primary diseases leading to MHD were chronic glomerulonephritis in 10 cases,diabetic nephropathy in 5 cases,hypertensive benign arteriolar nephrosclerosis in 2 cases,and renal tuberculosis in one case.They were treated with conventional hemodialysis using polysulfon membrane 1.4 m2 dialyzer 3 times a week.Pulmonary artery hypertension （systolic pulmonary artery pressure ≥ 35 mmH） was estimated by Doppler echocardiography.Dry weight adjustment was conducted in patients with pulmonary artery hypertension for one month.Blood pressure,hemoglobin,serum phosphorus,parathyroid hormone,plasma brain natriuretic peptide,transverse and longitudinal diameters of right atrium,inner diameter of pulmonary artery,and pulmonary artery systolic blood pressure by echocardiography were compared before and after the dry weight adjustment.Results After the down-regulation of dry weight,pulmonary arterial pressure decreased from 48.00±8.15 mmHg before treatment to 42.00±6.75 mmHg after the treatment （P＜ 0.05）,and plasma brain natriuretic peptide concentration from 7467.8±2357.4 pg/ml to 4759.2±1367.9 pg/ml.In addition,transverse diameter of right atrium decreased from 32.19±7.93 mm before the treatment to 26.84± 4.23 mm after the treatment,longitudinal diameter of right atrium from 43.09±8.95 mm to 35.96±8.69 mm,pulmonary artery diameter from 25.18±4.06 mm to 21.64± 2.49 mm,left ventricular diameter from 56.15± 6.28 mm to 50.25±5.39 mm,and left ventricular ejection fraction increased from 43.2±12.3％ to 55.3±13.6％.All of these changes were statistically significant （P＜0.05）.The changes of blood pressure,hemoglobin,serum parathyroid hormone,calcium,and phosphate were also statistically significant as compared with those before treatment （P＞0.05）.Conclusion In MHD patients with pulmonary hypertension treated with the downregulation of dry weight,excessive water can be eliminated,resulting in the decreases of transverse diameter of right atrium,pulmonary artery diameter,pulmonary pressure,right ventricular diameter,the pressure on left ventricle,and left ventricular diameter,and thereby in the improvement of left ventricular function and left ventricular ejection fraction.