动态血压监测在慢性肾脏病患者血压管理中的应用价值

高血压和慢性肾脏病（chronic kidney disease,CKD）互为因果。动态血压监测（ambulatory blood pressure monitoring,ABPM）较诊室血压可更准确和全面地评估CKD患者血压状态,预测CKD患者心肾的不良预后。我们从高血压类型、血压节律改变和血压变异性等三个方面阐述A...     

动态血压监测在慢性肾脏病中的运用

高血压的诊断取决于准确的血压测量,尤其在治疗慢性肾脏疾病,必须早期抗高血压治疗,预防心血管事件的发生.动态血压监测的重复性好,较少受主观因素干扰,能较全面、客观地反映24h血压的总体水平,动态波动规律及昼夜节律.动态血压监测在慢性肾脏病患者的高血压监测中表现出其特有的特征,且对心血管事件的预测优于诊室血压,与靶器官的损害密切相关.     

动态血压监测在肾脏病领域中的应用

慢性肾脏病（CKD）常伴有高血压,是继发性高血压的主要原因,而肾脏又是高血压损伤的重要靶器官。高血压是CKD患者肾功能损害加重的重要因素,血压昼夜节律消失是CKD的高危因素。认识CKD血压变化的规律,降低血压、调整血压昼夜节律,对延缓CKD的进展及心血管并发症的防治有重要的意义。     

可变钠碳酸氢盐透析对血液透析患者血压的影响

高血压是引起血液透析（血透）患者并发心血管疾病和病死率升高的重要因素。欧洲的记录显示８３％的透析患者需要降压药物,５０％～８５％的充分透析的患者血压没有完全控制［１］。在美国,Ｓａｌｅｍ［２］对６４９个血透患者的调查显示７２％的患者有高血压,并表现出对降压药物的抵抗。为了研究透析对血压的影响,我们设计了透析液钠浓度变化曲线,并与标准曲线进行对比,现报告如下。 一、对象与方法 １．研究对象：选择在我院血液净化中心进行维持性血液透析、无严重心肺功能障碍的慢性肾功能衰竭患者３１例（男 ２０例,女 １１例）…     

血液透析治疗中的血压降低与高血压

为观察不同年龄组患者透析中血压降低与高血压的发生率,探讨血压异常与超滤量（ＵＦＶ）和每公斤体重超滤量（ＵＦＶ／Ｗ）的关系,以确定透析中安全、合适的超滤量,我们对２ ８８０例次透析资料进行研究,结果如下。 一、对象和方法 １．病例及分组：选择本院接受常规血透的５０例患者（男２８例,女２２例）从１９９５年６月－１９９６年２月间的２ ８８０例次透析资料。年龄２９－８５（５６±１４）岁,透析时间７－３３ （１６±７）月。患者按年龄分为４组：组Ｉ：年龄＜４５岁（ｎ＝１１）,组Ⅱ：４５岁≤年龄＜５５岁（ｎ＝１１…     

一氧化氮和内皮素对血液透析中血压的影响

一氧化氮和内皮素对血液透析中血压的影响刘章锁耿晓仲明亮李全民李中和刘钟明内皮源性血管舒张因子／一氧化氮（ＥＤＲＦ／ＮＯ）及缩血管因子／内皮素（ＥＤＣＦ／ＥＴｓ）是近年来发现的体内一组强大的血管活性物质。它对血压的调节和控制具有重要作用［ＪＬａｂＣｌｉ...     

维持性血液透析患者血压晨峰和心脑血管疾病关系的临床观察

目的探讨维持性血液透析(maintenance hemodialysis,MHD)患者血压晨峰与心脑血管疾病发生的关系。方法选取四川省眉山市人民医院肾内科242例MHD患者采用动态血压监测仪记录24 h血压,根据血压晨峰分为血压晨峰组(44例)和非血压晨峰组(198例)。采集2组患者相关的研究数据,记录发生的心脑血管疾病,随访3年,比较2组患者一般资料、心脑血管疾病发生率及病死率。结果①2组患者24 h平均收缩压(24hSBP)比较差异有统计学意义(P0.05),血白蛋白、血红蛋白、血钙、血磷和24 h平均舒张压(24hDBP)比较差异无统计学意义(P0.05)。②血压晨峰组的24hSBP、白天平均收缩压(dSBP)、夜间平均收缩压(nSBP)、QT离散度、左心室质量指数分别为(152±14)mmHg、(158±10)mmHg、(124±12)mmHg、(56.2±14.6)、(132.8±4.0)g/m~2,与非血压晨峰组比较差异有统计学意义(P0.05);晨起时2hSBP、24 h平均脉压(24hPP)、动脉内膜-中膜厚度分别为(168±17)mmHg、(62.5±12.6)mm-Hg、(1.18±0.32)mm,与非血压晨峰组比较,差异有统计学意义(P0.01);2组患者24hDBP、dDBP、nDBP、夜间最低DBP和晨起时2hDBP比较,差异无统计学意义(P0.05)。③血压晨峰组的心脑血管疾病发生率(63.6%)及病死率(27.3%)显著高于非血压晨峰组(22.7%,8.1%)(P0.01)。结论 MHD患者存在血压晨峰现象,血压晨峰与MHD患者心脑血管疾病密切相关,可能是MHD患者心脑血管疾病的独立危险因素。     

血液透析中血压变异性随年龄变化特点及影响因素分析

目的 探讨不同年龄组维持性血液透析(maintenance hemodialysis,M HD)患者透析中血压变异性(blood pressure variability,BPV)差异和相关影响因素.方法 选取首都医科大学附属北京同仁医院M HD患者102例,根据年龄分为青年组(<45岁)32例,中年组(45≤,<60...     

血液透析患者血压昼夜紊乱与左心室结构及功能改变

目的 观察维持性血液透析(HD)伴高血压的患者昼夜血压节律变化的特点以及与左心室结构和功能改变的关系。方法 对31例伴高血压的HD患者进行持续1年的观察，分别在研究开始时、6个月和12个月时进行24h血压监测(ABPM)；在开始时和第12个月时行心脏彩色多普勒检查。结果 平均睡眠时收缩压/舒张压水平高于清醒状态时，平均睡眠收缩压/清醒收缩压是1．1—1．2(正常者是0.92)，平均睡眠舒张压/清醒舒张压是0．96—1．1(正常者是0．90)。在研究结束时，31例患者中有24例(77．8％)呈反常血压曲线，7例呈正常曲线。心脏彩色多普勒显示，反常曲线组左心室明显扩大，左心功能减弱。两组间生化检查、透析指标和降压治疗无差异。结论 反常血压曲线现象普遍存在于HD伴高血压的患者，是此类患者心脏结构和功能改变的重要因素之一。     

Clinical uses of ambulatory blood pressure monitoring

Traditional office measurements of blood pressure are commonly used to initiate and monitor therapy for hypertension, but these measurements are limited in their ability to provide information from the patient's normal work or play environment and do not include data from the overnight period when the patient is asleep. Thus, much potentially important information is lost. The ambulatory blood pressure monitor offers the attractive advantage of providing multiple blood pressure measurements from a subject's normal environment during his normal activities, thereby revealing important patterns of blood pressure in health and in illness. Further, the results of ambulatory monitoring have an excellent correlation with end-organ damage and these data can be obtained in a very short time period. This review will discuss the chronobiology of blood pressure, the clinical uses of the ambulatory blood pressure monitor in health and in disease, including the patterns of blood pressure identified, correlation with end-organ damage and its uses in clinical trials of antihypertensive medications; the experience in children with this technology will also be discussed.     

Intradialytic blood volume monitoring in ambulatory hemodialysis patients: a randomized trial

Complications related to inadequate volume management are common during hemodialysis. This trial tested the hypothesis that availability of an intradialytic blood volume monitoring (IBVM) device improves fluid removal, reducing morbidity. A six-center, randomized trial with 6 mo of intervention comparing IBVM using Crit-Line versus conventional clinical monitoring was conducted. The average rate of non-access-related hospitalizations was compared across treatment groups using Poisson regression. Mortality analysis used the Kaplan Meier method. A total of 227 patients were randomized to Crit-Line, and 216 were randomized to conventional monitoring. Both groups had similar baseline characteristics. During the study, no differences in weight, BP, or number of dialysis-related complications were observed. There were 120 and 81 non-access-related hospitalizations in the Crit-Line and conventional monitoring groups. The adjusted risk ratio for non-access-related and access-related hospitalization was 1.61 (95% confidence interval 1.15 to 2.25; P = 0.01) and 1.52 (95% confidence interval 1.02 to 2.28; P = 0.04) for the Crit-Line monitoring group. Mortality was 8.7% in the Crit-Line monitoring group and 3.3% in the conventional group (P = 0.021). Standardized mortality ratios comparing the Crit-Line and conventional monitoring groups to the prevalent hemodialysis population were 0.77 (NS) and 0.26 (P < 0.001). Hospitalization rates were 1.51 and 1.03 events/yr in the Crit-Line and standard monitoring groups, compared with 2.01 for the prevalent hemodialysis population. IBVM was associated with higher nonvascular and vascular access-related hospitalizations and mortality compared with conventional monitoring. The atypically low hospitalization and mortality rates for the conventional monitoring group suggest that these findings should be generalized to the US hemodialysis population with caution.     

Clinical usefulness of ambulatory blood pressure monitoring

During the past decade, several prospective studies showed that ambulatory BP (ABP) measurements provide a better prediction of major cardiovascular events when compared with clinic BP measurements. This review summarizes the available evidence supporting the use of ABP monitoring to refine prognostic stratification in hypertension. On the basis of available evidence, an operational flowchart is suggested to interpret results of ABP for better treatment of patients with elevated BP.     

Effect of exercise training on interdialytic ambulatory and treatment-related blood pressure in hemodialysis patients

BACKGROUND: Exercise training improves blood pressure (BP) in the general population, but prior studies in hemodialysis (HD) patients only used pill counts or treatment-related BPs. We evaluated the effect of 3 to 6 months of intradialytic exercise training on ambulatory blood pressure (ABP) and treatment-related pre- and postdialysis BP. PATIENTS AND METHODS: Nineteen chronic HD patients trained with an exercise bicycle for 30 to 60 min in the first 1 to 2 hr of each of thrice weekly HD. Interdialytic 44-hr ABP was performed a week before training began and repeated at 3 and 6 months. Pre- and post-HD systolic and diastolic BP and pre- and post-HD weight were recorded for 2 months prior to training, throughout the training, and, if available, for the 2 months after training ended. BP medications were recorded throughout. Body composition by bioimpedance, and norepinephrine and epinephrine levels by RIA were done at 0, 3, and 6 months. RESULTS: Thirteen subjects who completed at least 3 months of training exercised 90% of HD sessions for 56 min +/- 23 SD each. Systolic and diastolic 44-hr interdialytic ABP fell during training (systolic 138.4 mmHg +/- 19.6 vs. 125.7 mmHg +/- 20.0 vs. 125.9 mmHg +/- 22.9; diastolic 83.2 mmHg +/- 10.2 vs. 74.7 mmHg +/- 9.0 vs. 73.9 mmHg +/- 11.8 at 0, 3, and 6 months; p < .05 ANOVA). Norepinephrine and epinephrine levels did not independently predict systolic BP. Pre-HD systolic BP was stable during the pretraining period, fell significantly during the training period (p < .03), and returned toward preexercise levels during the posttraining period (p < .001). Pre- or postweight, erythropoietin dose, total body water, and number of BP meds were unchanged. CONCLUSION: Exercise training during HD significantly improves both interdialytic ABP and treatment-related BP.     

Agreement on reporting of ambulatory blood pressure monitoring in children

The use of ambulatory blood pressure monitoring (ABPM) can improve the accuracy of paediatric BP measurement and may better correlate with end-organ injury than office BP measurement. However, the interpretation of ABPM may be influenced by several variables. We sought to ascertain the agreement among three paediatric nephrologists when reporting 92 ABPM sessions performed on patients aged 5 to 18 years. All three nephrologists were in agreement on the presence or absence of hypertension in 64% of cases. They were less likely to concur about records where hypertension was borderline or if the ABP record contained fewer BP readings. These results highlight the need for evidence-based consensus regarding the interpretation of ABPM in children.     

Effect of placebo on ambulatory blood pressure monitoring in children

Background

Ambulatory blood pressure monitoring (ABPM) has been proposed as a useful tool for more accurately diagnosing hypertension (HTN) and evaluating blood pressure (BP) response in pediatric anti-hypertensive trials. ABPM captures multiple BP measurements during routine daily activities and is thus an excellent method for identifying white-coat HTN. Additionally, ABPM measurements in adults do not demonstrate the placebo effect commonly seen with casual BP measurements, although this has yet to be evaluated in children. Therefore,, the aim of this study was to assess the effect of placebo on ABPM measurements in children.

Methods

A total of 141 children aged 5–16 years with elevated BP were randomized into a multi-center, single-blind, cross-over trial. Subjects received a placebo pill prior to wearing a 24-h ABPM device at one of two visits separated by 1–2 weeks. Study procedures were otherwise identical at both visits.

Results

Mean systolic and diastolic BP for all measured time periods were similar between visits, as was the number of children diagnosed with HTN at each visit.

Conclusion

Having confirmed HTN at baseline did not affect the impact of placebo on mean BP. If confirmed, this lack of placebo effect on ABPM measurements may allow for the design of direct comparison pediatric anti-hypertensive trials without a placebo arm.     

Twenty-four-hour ambulatory blood pressure monitoring in young children

 Twenty-four-hour ambulatory blood pressure monitoring (ABPM) has many advantages for the diagnosis and follow-up of hypertension at all ages. This technique has so far not been documented as applicable to the very young. We studied the feasibility of ABPM in 61 healthy children and in 40 patients with renal diseases and/or hypertension, aged less than 6 years. A satisfactory ABPM profile (recording time = 24 h and >30 good recordings) was obtained in 77% of the healthy children. The mean number of good blood pressure (BP) measurements per 24 h increased with age from 46 (3–4 years) to 58 (6 years). The mean (±SD) systolic and diastolic BPs of healthy 3- to 6-year-old children (n = 47) were 110±5/67±5 mmHg during the day-time and 100±5/58±5 mmHg at night. In addition to the nocturnal decrease in BP, ABPM detected a second, day-time dip in BP during bed rest after lunch. Ninety percent of patients with renal disease and/or hypertension had successful ABPM recordings for 24 h, with an age-dependent increase in the mean number of reliable readings from 34 (< 2 years) to 48 (4 years). In 5 of 10 children with hypertensive results obtained by casual BP measurements, elevated BP was not confirmed by ABPM. We conclude that ABPM is a useful tool for the diagnosis and evaluation of hypertension in children under 6 years of age. Received March 5, 1996; received in revised form and accepted May 6, 1997