非对称性二甲基精氨酸与血液透析中血压变化的研究

目的研究血液透析(Hemodialysis,HD)患者血浆非对称性二甲基精氨酸(Asymmetric dimethylarginine,ADMA)与透析中血压变化的关系。方法经生物电阻抗检测干体质量达标且符合入选标准的维持性血液透析(Maintenance Hemodialysis,MHD)患者31名进入研究,根据血液透析过程中血压波动情况分为年龄相匹配的3组:透析中高血压组(n=11)、低血压组(n=12)和血压平稳组(n=8)。用酶联免疫吸附(Enzyme linked immunosorbent assay,ELISA)法检测患者透析前、后血浆ADMA水平,探讨ADMA与透析中血压变化的关系,并进行组间矿物质骨代谢指标、电解质、营养指标、炎性标记物、血脂水平、脉压差和降压治疗等的比较。结果 31例MHD患者透析前血ADMA均值为3.37±1.48μmol/L,透析后降至1.71±0.80μmol/L(P0.001),均显著高于国外正常参考值。透析中低血压组透析前、后血ADMA值(4.38±1.56μmol/L,2.25±0.83μmol/L)均高于透析中高血压组和血压平稳组,差异有统计学意义(2.70±1.18μmol/L,1.32±0.60μmol/L和2.78±0.88μmol/L,1.43±0.56μmol/L;P=0.006和0.006)。透析中高血压组患者透析中的平均脉压差高于透析中低血压组和血压平稳组(62.41±11.57mmHg,48.80±12.88 mmHg和44.56±8.30 mmHg,P=0.004)。高血压组碱性磷酸酶(ALP)、总胆固醇(TC)、低密度脂蛋白胆固醇(LDL-C)和高敏C-反应蛋白(high-sensitivity c-reactive protein,Hs-CRP)均高于血压平稳组(P值分别为0.036、0.039、0.046、0.046),低血压组同样指标也高于血压平稳组(P值分别为0.046、0.035、0.040、0.004),上述指标在高血压组和低血压组间差异无统计学意义(P0.05)。结论在干体质量达标的MHD患者中,血ADMA水平显著高于正常,透析过程中的血压波动与内皮功能不良、血管僵硬、微炎症状态等密切相关。

Investigation of the relationship between intradialytic blood pressure change and plasma asymmetric dimethylarginine

Objective To study the correlation between plasma asymmetric dimethylarginine （AD- MA） level and blood pressure change during hemodialysis （HD） session in end-stage renal disease patients. Methods Thirty-one patients on maintenance hemodialysis （MHD） for more than six months were enrolled in this study. They had appropriate dry body weight detected by bioelectrical impedance. Based on intradialytic blood pressure change, the 31 MHD patients were divided into intradialytic hypertension, hypotension and sta- ble blood pressure groups. Plasma ADMA was measured by enzyme linked immunosorbent assay （ELISA） be- fore and after HD session. The correlation between ADMA and blood pressure change during HD session was investigated. The possible influential factors including metabolic bone disease indexes, electrolytes, nutrition status, micro-inflammatory status, serum lipids, pulse pressure difference, and antihypertensive therapy were compared between the three groups. Results Plasma ADMA elevated at the beginning and fell at the end of HD sessions in MHD patients （3.37± 1.48 μmol/L vs. 1.71±0.80μmol/L）, both higher than the normal refer- ence interval from foreign countries. The plasma ADMA values before and after HD were significantly higher in the intradialytic hypotension group （4.38±1.56 μmol/L and 2.25±0.83 μmol/L, respectively） than in the in- tradialytic hypertension group （2.70± 1.18 μmol/L and 1.32±0.60 μmol/L, respectively; P=-0.006） and intradia- lyric stable blood pressure group （2.78±0.88μmol/L and 1.43±0.56 μmol/L, respectively; P=0.006）. The pulse pressure difference was significantly higher in intradialytic hypertension group （62.41±11.57 mmHg） than in intradialytic hypotension group and intradialytic stable blood pressure group （48.80q-12.88 mmHg and 44.56±8.30 mmHg, respectively; P=0.004）. Alkaline phosphatase （ALP）, total cholesterol （TC）, low density lipopro- tein cholesterol （LDL-C） and high-sensitivity c-reactive protein （Hs-CRP） were higher in intradialytic hyper- tension and intradialytic hypotension groups than in intradialytic stable blood pressure group （P〈0.05）, but were statistically insignificant between intradialytic hypertension and hypotension groups （P〉0.05）. Conclu- sion ADMA was significantly elevated in MHD patients with appropriate dry body weight. The intradialytic blood pressure fluctuation was closely related to endothelial dysfunction, micro-inflammation and vascular stiffness.