血液透析患者血容量监测的意义

目的了解血容量监测对评价透析患者干体重和防治透析患者难治性高血压、透析中低血压中的作用.万法38例规律性血液透析患者,其中男8例,女30例,患者平均年龄(54.2±11.5)岁,其中2例为糖尿病肾病.根据患者临床表现分为病情稳定组(A)、低血压倾向组(B)和难治性高血压组(C).对所有患者进行血红蛋白、血清白蛋白、超声心动图和透析充分性检查,观察透析前后血压、心率及体重,透析中监测超滤量、血压、心率、临床症状和血容量变化.结果A组27例,一次透析血容量下降(△BV)5.1%～26.1%之间,其中△BV＜15%者和△BV＞15%者临床指标无明显差异;B组9例,△△BV在12.5%～22.6%之间,和A组患者相比,年龄偏大(P=0.03)和脱水量过多(P=0.006),两组之间的其他因素无显著性差异.对其中3例透析中发生低血压患者在血容量监测的指导下上调干体重,透析结束时血容量下降程度明显好转(21.03%±1.99%vs16.06%±2.03%,P=0.04),未再发生低血压.C组2例,△BV＜5%,在连续血容量监测下,下调干体重后,血压得到有效控制.结论在透析过程中,患者所能耐受的血容量下降程度存在着明显的个体差异.根据患者临床表现结合血容量监测有助于确定合适的超滤量、调整干体重、防治透析过程中低血压和指导治疗透析患者难治性高血压.     

不同超滤模式透析对维持性血液透析患者血容量及血压的影响

目的 观察维持性血液透析患者采用不同超滤模式透析对血容量及血压的影响.方法 稳定血液透析患者12例,采用标准透析(SD)、线性超滤模式透析(UP1:起始超滤率为匀速超滤时的1.33倍,线性降低至透析结束)和阶梯状超滤模式透析(UP2:透析前1/3时间超滤率为匀速超滤的1.5倍,中间1/3时间超滤率等同于匀速超滤,后1/3时间超滤率为匀速超滤的0.5倍)各进行10次,在线监测透析过程中相对血容量(RBV)、平均动脉压(MAP)及发生症状性低血压的例次.结果 (1)透析间期体重增长量及透析中脱水量在3种模式之间比较均无明显差异;(2)透析1小时、2小时、3小时、4小时的Upl和UP2相对血容量低于SD(P<0.001),透析1小时、2小时时UP2低于UP1(P<0.05);(3)UPl在透析2小时、3小时、4小时、5小时MAP均低于SD(P<0.05).UP2模式在透析中MAP均低于SD(P<0.05),UP2模式在透析2、3、4小时MAP低于UP1(P<0.05);(4)SD与UP1发生低血压的例次比较无明显差异,UP2模式出现低血压次数多于SD和UP1,其中1人因6次透析中4次低血压,不得不提前终止此模式.结论 单纯使用超滤模式,特别是阶梯状超滤模式透析,透析早期脱水速度过快,血容量变化大,易引起症状性低血压的发生.     

联合生物电阻抗监测血容量在评估血透患者容量超负荷中的诊断价值

目的探讨联合生物电阻抗对相对血容量监测在评估血液透析患者容量超负荷的诊断价值。方法选取2011年8月到2012年1月在河北医科大学第四医院行维持性血液透析治疗患者49例,临床评估均达到干体重,根据透后30 min生物电阻抗测量结果分为两组,A组:达干体重组(34例),B组未达干体重组(15例)。对B组患者逐渐下调干体重,直至再次测量生物电阻抗结果达正常人群标准时,定为B'组(n=15)。在透析过程中同时应用在线血容量监测(BVM)监测患者相对血容量变化(ΔBV)。比较A、BΔBV/UF(%/L)、ΔBV/UFR(%·L-1·h-1)值,并应用ROC曲线分析计算ΔBV/UF、ΔBV/UFR在诊断容量超负荷时的曲线下面积,寻找诊断容量超负荷的较好指标。结果ΔBV、ΔBV/UF、ΔBV/UFR,B组均低于A组(P<0.01)。A组与B'组中比较均没有显著差异(P>0.05)。诊断容量超负荷时的曲线下面积为:ΔBV/UF(0.84,95%CI 0.70⁰.93)>ΔBV/UFR(0.83,95%CI 0.690.93)>ΔBV/UFR(0.83,95%CI 0.69⁰.92)。结论ΔBV/UF、ΔBV/UFR是诊断血液透析患者容量超负荷的较好指标,在△BV/UF低于4.53%/L或△BV/UFR低于0.88%·L-1·h-1的血流动力学稳定的患者,提示存在容量超负荷,可以安全地下调干体重。     

血液透析中低血压防治专家共识（2022）

血液透析中低血压是维持性血液净化患者常见并发症之一,发生机制复杂,预防和治疗亦较为困难,严重影响了透析患者的生存质量和生存率。为提高对血液透析中低血压的认识,规范其诊断与防治,中国医药教育协会肾病与血液净化专业委员会血液透析低血压防治专家组基于目前临床研究结果,经过多次讨论修改,制定了《血液透析中低血压防治专家共识》,...     

老年人血液透析中低血压的治疗观察

透析低血压是血液透析中常见的急性并发症。本文将老年组与非老年组血液透析的低血压发生率进行了比较，并对血液透析的低血压发生的原因及其防治措施进行观察。     

维持性血液透析患者透析相关性低血压的防治

目的 分析透析相关性低血压发生的病因,探讨针对主要病因进行个体化透析治疗在降低低血压发生率中的重要性.方法 对血液透析过程中发生低血压的21例患者进行自身前后对照分析,前1个月收集低血压患者的病因资料,第2个月为调整分析期,运用柏拉图分析法结合鱼骨图解析,找出低血压主要病因,针对主要病因进行宣教及调整治疗方案;第3个月再次统计低血压发生率及具体病因,比较干预治疗前后低血压发生率及病因的变化.结果 低血压主要病因是脱水量/干体重＞5％、糖尿病、透析过程中进餐、透析前不合理服用降压药物等,21例患者干预前后2个月共行血液透析534例次,干预后低血压发生率明显下降,干预前后低血压发生率分别为7.7％ (39/260)和3.3％(9/274),两组比较差异有统计学意义(P＜0.01).透析相关性低血压多出现在透析后3小时.结论 对不同患者寻找低血压病因,针对主要病因进行重点宣教及个体化透析,可明显降低血液透析过程中低血压的发生率.     

血液透析病人血压控制与血容量变化之间的关系

目的 了解血液透析病人血压控制与血容量变化之间的关系。方法 根据JNC诊断标准将血液透析病人分为高血压组及正常血压或低血压组。用多频率生物阻抗分析仪(Xitron 4200)测定透析病人透析前后的血容量,并根据细胞外液容量(ECW)的变化将透析病人分为血容量减少较多及较少组,分别分析它们与血压控制的关系。结果 细胞外液容量(ECW)减少越多,血压控制越理想。结论 血液透析病人高血压的主要发生机制可能是血容量过多,血容量控制越好,血压控制越好。     

血液透析中并发低血压的原因及护理对策

目的探讨维持性血液透析患者在治疗过程中并发低血压的原因及护理对策。方法对行维持性血液透析治疗的210例患者,在治疗中发生低血压的原因进行分析并采取相应的护理对策。结果18 139例次患者发生低血压1 676次,发生率为9.24%。主要原因包括有效循环容量的减少、植物神经功能紊乱、内分泌及透析液因素、降压药等方面,所有患者经抢救治疗后均好转,无一例死亡。结论加强对患者的健康宣教,控制超滤脱水量,制定合理的透析方案,积极治疗基础疾病及治疗中严密观察病情变化等是预防血透并发低血压发生和保证透析效果的关键。     

血液透析过程中低血压的护理体会

血压降低是血液透析中常见的急性并发症之一，指透析时平均动脉压比透析前下降30mmHg以上，或者收缩压降至90mmHg以下，主要原因为有效循环血量不足、血浆渗透压下降、植物神经病变、透析膜生物相容性差、透析液成分及温度不合适、透析过程中进餐、营养不良及贫血、服用降压药或镇静药。2003年5月～2004年5月，我们共为71例患者行血液透析2865次，其中256次发生透析低血压，发生率占8．9％。现将护理体会报告如下。     

动态血压监测对老年体位性低血压评价的探讨

目的探讨动态血压监测（ABPM）技术对老年体位性低血压的评价价值。方法对152例门诊老年人进行卧位及立位3min血压测量,根据血压变化将患者分为体位性低血压组及非体位性血压组。对所有患者进行动态血压监测,计算并比较两组全天、白天以及夜间的平均血压、平均脉压、血压负荷、血压变异系数、动态动脉硬化指数以及24h血压昼夜节律。结果体位性低血压组的夜间平均收缩压、夜间平均舒张压、夜间收缩压负荷、夜间舒张压负荷、全天收缩压变异系数均高于非体位性低血压组,血压昼夜节律以反杓型为主。结论动态血压监测在老年体位性低血压的用药指导中有着重要的临床作用;老年体位性低血压存在夜间高血压、卧位高血压、收缩压波动范围大、血压昼夜节律异常的特点,上述特征均可造成重要靶器官的损伤。     

The placebo effect in ambulatory blood pressure monitoring

The reduction of clinic blood pressure by placebo tablets in clinical trials of antihypertensive drugs is well established and health authorities require a placebo arm in these trials in order to know how much of the total reduction of blood pressure is attributable to the drug. Most authors now favor the hypothesis that, in contrast to clinic blood pressure measurements, ambulatory blood pressure monitoring (ABPM) is not subject to a placebo effect. Scientific evidence so far shows that ABPM recordings are affected by a negligible and clinically irrelevant placebo effect in short-term trials. Nevertheless, the results of the SYST-EUR study suggest that placebo treatment induces a reduction of blood pressure in old patients with isolated systolic hypertension even when blood pressure is measured by 24 h ABPM, and raise the question of whether a placebo arm is required in clinical trials when ABPM is used to measure changes in blood pressure. In this article, the evidence supporting and contradicting the hypothesis that placebo exerts an effect on ABPM and the possible explanations for the discrepancy are reviewed. My position is that clinical trials on antihypertensive drugs using ABPM should be designed with the same standards as those using clinic blood pressure measurements; that is, randomized, double-blind, placebo-controlled studies. This should be an absolute requirement in long-term trials. Short-term trials lasting no more than 12 weeks, particularly those focused on examining average changes in 24 h diastolic blood pressure, may be designed without a placebo arm.     

The role of ambulatory monitoring in reducing the errors associated with blood pressure measurement

The measurement of blood pressure for the clinical evaluation of hypertensive subjects is subject to three types of error. First is the error due to the measurement procedure itself. Although noninvasive methods are less accurate than invasive ones, they are preferred for clinical use both because of their convenience and safety, and because they form the basis of our knowledge of the risks associated with hypertension. Most automatic recorders use either the Korotkoff sound or oscillometric techniques, which generally provide an acceptable accuracy (to within 5 mmHg), although a new method (the K2 technique) may be the most accurate. The second error arises from the spontaneous variability of blood pressure, such that single clinic readings may vary by as much as 20 mmHg. This error can be reduced by multiple readings, e.g. obtained with ambulatory monitoring. The third type of error arises from a spurious elevation of blood pressure in the clinic (the white coat effect), which also may be as much as 20 mmHg. This can be reduced by including readings taken outside the clinic, e.g., by self- or ambulatory monitoring.     

脑血管病危险因素干预对血压变化及脑卒中发病情况的影响

目的 分析脑血管病危险因素干预对血压变化及脑卒中发病情况的影响。方法 1987年在长沙市社区人群中选择两个社区作为干预和对照人群，检测血压并随访脑卒中发病情况。结果 14年后，干预和对照两组队列人群的脑血管病的累计发病人数分别为89例和128例；两组人群血压均随年龄的增长而增加，但对照组增加明显；对脑卒中发病情况绘制K—M线显示干预队列未发生脑卒中的比率明显高于对照组(P=0．005)；COX回归模型显示对照组脑卒中的发病危险是干预组的1．4倍；基线收缩压处于130～139mmHg水平和基线舒张压处于80～84mmHg、85～89mmHg水平时只在对照组对脑卒中的发病存在危险性。结论 长期脑血管病危险因素干预可以延缓血压随年龄增长而逐渐增高的现象、降低基线血压对脑卒中发病的危险及降低脑卒中的发病。     

Arterial hypotension: prevalence of low blood pressure in the general population using ambulatory blood pressure monitoring

BACKGROUND: Chronic constitutional hypotension has been described in a proportion of the population, and has a symptom complex ascribed to it. The true prevalence of low blood pressure in the normal population has not been defined. AIM OF STUDY: This study was undertaken to determine the prevalence of low blood pressure states, as measured using ambulatory blood pressure monitoring, in a general population cohort, and to determine the association between low blood pressure and clinical and demographic variables. PATIENT POPULATION: The population enrolled were a cohort of mainly urban dwelling Irish subjects, either employees or spouses of employees of a major national bank. METHODS: Subjects had an ambulatory blood pressure monitor fitted between 09.00 and 12.00 and wore the monitor for 24 hours. The subjects also filled out a detailed lifestyle questionnaire, and kept an activity diary. Blood was drawn for serum electrolyte estimation. RESULTS: A total of 254 subjects were included, 49% of whom demonstrated hypotensive events. Hypotensive means and individual hypotensive values were more frequently found in women, and occurred in a group of individuals with a distinct body habitus, specifically thin subjects, with a lower creatinine suggesting a smaller muscle mass. Hypotensive events in these subjects were associated with a low risk cardiovascular profile, in that subjects who displayed these events had a lower blood pressure, a lower weight and were less likely to have a positive family history of hypertension or vascular disease. CONCLUSION: Hypotension is common in the general population and is associated with a distinct body habitus. It carries a generally benign cardiovascular risk factor profile.     

The value of home blood pressure monitoring

Home blood pressure (BP) monitoring has become popular and acceptable. The value of home BP monitoring has been recognized, because it has some potential advantages over office BP. Home BP monitoring is more accurate and reproducible, has a better prognostic value, and increases patients’ compliance with treatment. Home BP monitoring should be performed with an adequate device, following a standardized procedure. The automated arm-cuff-oscillometric devices are recommended currently, and home BP should be measured at least twice daily, in the morning and in the evening. Home BP monitoring has revealed the phenomena ofldwhite-coat hypertension, “masked hypertension,” and “morning hypertension,” and it is useful for their management. In the future, home BP monitoring will be an essential aspect of clinical practice.     

Evaluation of the antihypertensive effect of celiprolol by ambulatory blood pressure monitoring

The use of ambulatory blood pressure monitoring has gained popularity because it is not subject to those limitations associated with traditional sphygmomanometry (inaccuracy of blood pressure readings, low number of readings, and failure to represent daytime blood pressure readings). In the present study, we provide evidence that the 24-hour mean blood pressure obtained through intraarterial blood pressure measurements in ambulatory patients provides a more accurate diagnosis (and perhaps a prognosis) of hypertension than that provided by cuff-obtained casual blood pressure measurement. Furthermore, despite a reduction in the amount and in the accuracy of the information obtained, blood pressure data provided by noninvasive blood pressure monitoring are also more accurate diagnostically than cuff-obtained casual blood pressure measurements. In 15 essential hypertensive patients in whom celiprolol, 400 mg once daily, was compared with placebo in a randomized double-blind crossover study, the use of noninvasive 24-hour automatic blood pressure monitoring showed that in responsive patients, celiprolol induced a sustained reduction in systolic and diastolic blood pressure throughout the 24 hours. The blood pressure reduction was also apparent during the night, despite the concomitant occurrence of a slight tachycardia. These findings demonstrate that once-daily administration of celiprolol provides an effective lowering of the 24-hour blood pressure profile. This dosing schedule can therefore be regarded as appropriate for antihypertensive therapy.     

Ambulatory blood pressure monitoring

Ambulatory blood pressure monitoring (ABPM) is becoming widely accepted as a clinically useful tool for assessing cardiovascular risk in hypertensive patients, although it is not generally recognized for reimbursement in the United States. There are now six major prospective studies, all of which have shown that ABPM gives a better prediction of risk than conventional clinic measurement. A corollary of these findings is that patients with white coat hypertension have been found to be at relatively low risk. The major clinical indications include patients with newly diagnosed hypertension, suspected white coat hypertension, and refractory hypertension. White coat hypertension is common during pregnancy and may lead to unnecessary cesarean sections.