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…     

传统维持性血液透析患者钠水平衡与高血压

目的 探讨传统维持性血液透析模式下透析患者钠水清除和高血压之间的关系.方法 血液透析组:3次/周,透析3个月及以上的维持性血液透析患者98例,收集人选病例最近1个月透析前的血压、血钠水平、脱水量占透析前体重的比例以及是否达到干体重等数据;未透析组:同期未进行过任何肾脏替代治疗的CKD4期、CKD5期所有住院患者118例,收集其入院当天的血压、血钠水平等.对组内和组间的数据以及与高血压之间的关系进行分析.结果 与未透析组相比维持性血液透析更好的控制了患者的血压(X2=10.767,P=0.001).两组组内高血压和血钠水平无相关关系,两组患者高血压和血钠之间存在等级相关关系(rs=0.151,p=0.027).透析组内达到干体重患者高血压的比例显著低于未达到干体重的患者(X2=16.450,P<0.01).结论 在低盐饮食的基础上,以超滤对流为主,配合以合适的透析液钠浓度弥散的方式为辅进一步完成对钠水的清除从而达到人体钠水平衡才是控制维持性血液患者高血压最重要的方案.     

血液透析患者干体重的获得及与高血压的关系

在慢性肾衰患者高血压发病机制的各种影响因素中，容量负荷过重是最主要的。理想干体重的获得，是临床透析中最棘手的问题。血液透析过程中细胞外液容量的减少，包含着对透析耐受性的改进。其中应该考虑的因素之一是透析时间。但是，使用其它一些技术措施来改善透析耐受性也可使大多数患者在4-5h透析中达到适当的干体重，从而使血压维持在较满意的水平。本文就血液透析患者干体重的评估，如何达到理想干体重及与高血压的关系作一综述。     

维持性血液透析患者高血压相关因素与对策

维持性血液透析患者高血压发生机制涉及到很多方面,其中容量因素是最主要的原因之一。心血管疾病是维持性血液透析患者的主要死亡原因,高血压是ESRD患者发生心血管疾病的主要危险因素。维持性血液透析患者的良好血压控制涉及到很多方面,需要综合评估,制定合理的方案,提高患者的生存时间。     

自我管理教育对维持性血液透析者血压及容量状况的影响

目的 探讨自我管理教育在维持性血液透析者血压及容量控制中的作用.方法 选择2012年2月至2013年2月在我院行维持性血液透析且合并高血压的患者56例,其中男31例,女25例,年龄29 ～ 75岁,平均（59±6）岁.在常规护理的基础上,以自我管理模式理论为指导,对患者进行疾病知识和管理技能培训,观察患者干预前与干预后3个月时血压及容量变化.采用t检验进行数据统计.结果 进行自我管理教育3个月后,患者血压及容量控制水平较干预前显著提高,体质量增长量及降压药物应用均有所下降,差异统计学意义（均P＜0.05）.结论 自我管理教育能有效提高维持性血液透析者的健康行为和自我管理能力,有效控制患者血压,改善患者容量状况.     

动态血压监测在血液透析患者中的应用

随着动态血压监测越来越广泛的应用,血液透析人群中的应用也逐渐增加。本文将对该技术在血液透析患者中应用的进展作一综述,同时也将分析动态血压各参数尤其是变异参数对于血液透析患者预后以及高血压治疗的指导意义。     

Epidemiological investigation of hypertension and its control on maintenance hemodialysis patients in Anhui province

Objective To understand the prevalence, treatment and influence factors of hypertension in maintenance hemodialysis (MHD) patients in Anhui Province. Methods A total of 2724 adult patients on MHD from January 1st 2014 to March 31st 2014 in 26 hospitals of southern, northern and central Anhui Province were investigated. Their demographic characteristics, primary disease, complications, medications, dialysis and laboratory examination were explored. The prevalence treatment rate and control rate of hypertension were analyzed. Associated factors for controlling hypertension [systolic blood pressure (SBP)＜140 mmHg and diastolic blood pressure (DBP)＜90 mmHg] were assessed by logistic regression analysis. Results (1) The prevalence of hypertension in the hemodialysis patients was 87.0%. Their treatment rate and control rate were 93.2% and 23.9% respectively. The average of SBP was (145.90±21.18) mmHg, and the DBP on average was (83.60±12.21) mmHg. The most commonly used anti-hypertensive drug is calcium channel blocker (88.2%). Over one third (45.7%) of patients were treated with two kinds of anti-hypertensive drug, 26.2% with 1 kind, 21.7% with 3 kinds, and 6.4% with 4 kinds or more. (2) Compared with non-hypertension patients, patients with hypertension have older age, higher body mass index (BMI), phosphorus, SBP and DBP, as well as lower hemoglobin and Kt/V (all P＜0.05). (3) The multivariate logistic regression analysis showed that Ca＞2.50 mmol/L (OR=2.084, 95%CI 1.008-4.307, P=0.047) positively correlated with controlling hypertension, while smoke (OR=0.594, 95%CI 0.356-0.911, P=0.046) and BMI 18.5～23.9 kg/m2 (OR=0.516, 95%CI 0.293-0.907, P=0.022) negatively correlated with it. Conclusions High prevalence yet low control rate of hypertension in MHD patients in Anhui Province were observed. Hypocalcemia may be a protective factor for hypertension control, while smoke and BMI may be risk factors for it.     

Blood pressure control in pediatric hemodialysis: the Midwest Pediatric Nephrology Consortium Study

Hypertension is frequent in pediatric patients receiving dialysis, with an especially high rate reported in children on hemodialysis (HD). We performed the present study to assess blood pressure (BP) status and identify risk factors for poor BP control in children on maintenance HD. One month’s dialysis records were collected from 71 subjects receiving HD in ten dialysis units participating in the Midwest Pediatric Nephrology Consortium (MWPNC). For each HD session, data on pre- and posttreatment weights and BPs were recorded. Hypertension, defined as mean BP ≥ 95th percentile, was found in 42 (59%) subjects. Eleven subjects (15.5%) had prehypertension, defined as mean BP between the 90th and 95th percentiles, while 18 subjects (25.3%) had normal BP (<90th percentile). BP significantly decreased at the end of a dialysis session; however, only 15 of 42 hypertensive subjects (35%) normalized their BP. Hypertensive subjects were younger (p = 0.03), had higher serum phosphorus (p = 0.01), and had more elevated posttreatment weight above estimated dry weight (p = 0.02). Logistic regression showed that younger age (p = 0.02) and higher serum phosphorus (p = 0.02) independently predicted hypertensive status. In conclusion, this study emphasizes the difficulty of BP control in pediatric HD patients. Especially poor BP control was found in younger children; those patients who do not reach their posttreatment weight goals, perhaps reflecting their hypervolemic state; and those who have higher serum phosphorus levels.     

Principles of drug dose adjustment during hemodialysis

Drug removal during dialysis is influenced by physical properties of the drug, its pharmacokinetics, and by the choice of artificial kidney. The amount of drug removed during dialysis can be estimated in several ways. If changes in drug concentration produced by dialysis are used, one must be certain that postdialysis drug reequilibration is complete.     

Blood pressure measurements and left ventricular mass index in hemodialysis patients

Left ventricular hypertrophy (LVH) is the most frequent cardiac abnormality in hemodialysis (HD) patients. It is related to cardiovascular diseases and is an important risk factor for mortality in HD patients. Arterial hypertension is an established risk factor for LVH in HD patients. Inferior vena cava (IVC) diameter is a good indicator of circulating fluid volume; hypervolemia is an important pathogenetic factor of hypertension in HD patients. The purpose of our study was to evaluate possible association between LVH, IVC diameter, and different blood pressure (BP) measurements in HD patients. In the present study, 85 HD patients were included. BP was measured with a standard mercury sphygmomanometer before and after the HD session; the average 1‐monthly values of the routine BP measurements were also analyzed. 24‐ and 48‐h ambulatory blood pressure measurements (ABPMs) were performed after the end of HD sessions using a noninvasive ABPM. Average values of systolic and diastolic BP were analyzed separately for the first (HD) and second (interdialytic) day ABPM and for both days together. Using echocardiography, left ventricular mass was measured and left ventricular mass index (LVMI) was calculated. Using ultrasonography, IVC diameter was measured on the interdialytic day. Using multiple regression analysis, we found statistically significant correlations between LVMI and mean monthly postdialysis systolic BP (P < 0.05) and mean 48‐h diastolic BP (P < 0.05). Only longer BP measurements (average 1‐month post‐HD and 48‐h ABPM) were associated with LVMI in HD patients.     

Association of short-term blood pressure variability with cardiovascular mortality among incident hemodialysis patients

Objective: To investigate the association of short-term blood pressure variability (BPV) with cardiovascular mortality in hemodialysis (HD) patients, using a reliable index called average real variability (ARV), and to assess the factors associated with ARV in incident HD population.

Methods: A total of 103?HD patients were recruited, with 44-h ambulatory blood pressure monitoring performed after the midweek HD session. Systolic BPV was assessed by SD, coefficient of variation (CV), and ARV, respectively. Laboratory data were obtained from blood samples before the midweek HD. All patients were followed up for 24 months.

Results: According to the median of BPV indices, the comparisons between patients with the low and high values were conducted. Kaplan–Meier analysis showed the survival curves corresponding to median of SD and CV exhibit similar performance for the low and high groups (p?=?.647, p?=?.098, respectively). In contrast, patients with higher ARV had a lower survival rate than those with lower ARV (77.8% vs. 98.0%, p?=?.002). After adjustment for demographics and clinical factors, ARV (HR: 1.143; 95% CI: 1.022–1.279, p?=?.019) and high-sensitivity C-reactive protein (HR: 1.394; 95% CI: 1.025–1.363, p?=?.021) were associated with increased risk of cardiovascular mortality in HD patients. Age and interdialytic weight gain (IDWG) were related factors for ARV (β?=?0.065, p?=?.005; β?=?0.825, p?=?.003, respectively).

Conclusions: Greater ARV was independently associated with increased risk of cardiovascular mortality in HD patients. Age and IDWG were independent related factors for ARV.     

血液透析患者原发病因及高血压和贫血状况的多中心调查

目的调查佛山地区血液透析患者的原发病因及高血压、贫血状况。方法收集2012年佛山市21家医院2610例血液透析患者的基本情况、原发病因、合并高血压、贫血状况、血白蛋白水平等有关临床资料进行分析。结果佛山地区21家医院2610例血液透析患者中,其原发病分别为原发性肾小球肾炎1278例（占48．9％）、糖尿病肾脏疾病505例（占19．3％）和高血压肾损害219例（占8．4％）。梗阻性肾病、痛风性肾病、多囊肾病、狼疮肾炎、小管间质性。肾病、其他原因及原因未明者分别为191例（占7．3％）、65例（占2．5％）、60例（占2．3％）、39例（占1．5%）、26例（占1．0％）、89例（占3．4％）、138例（占5．3％）。血液透析患者高血压患者1804例,其发病率达86．6％,治疗率为83．7％,血压控制低于140／90mm Hg水平者1227例（占47.0%A）,血压控制不达标1383例（占53％）。高血压控制常需多种降压药联合应用,仅269例（占14．9％）患者应用1种降压药,应用2、3、4和5种或5种以上者分别为529例（占29．3％）、606例（占33．6％）、312例（占17．3％）和86例（占4．9％）。血红蛋白（hemoglobin,Hb）〈110g／L的患者1832例（占70．2％）,Hb≥110g／L者仅778例（占29．8％）。有493例（占18．9％）患者血浆白蛋白水平低于35g／L,有647例（占24．8％）患者血浆白蛋白水平高于40g／L。结论血液透析患者的病因主要是原发性肾小球肾炎、糖尿病肾脏疾病、高血压肾损害、梗阻性肾病,高血压和贫血控制不达标仍较突出。     

血液透析患者并发肺动脉高压的临床分析

目的　探讨慢性肾衰竭血液透析（HD）患者并发肺动脉高压（PAH）的发生率和临床特点,以便早期诊断PAH并进行干预。 方法　收集首都医科大学附属北京朝阳医院肾内科2000年1月至2007年12月资料完整的维持性血液透析（MHD）患者184例的临床资料,进行回顾性分析。PAH的确定按照超声心动图诊断标准。 结果　184例中并发PAH 65例（35.3%）,其中男34例,女31例,平均年龄（56.84±14.58）岁,透析龄（29.69±21.61）个月。PAH组患者使用动静脉内瘘61例,深静脉置管4例。PAH组静息肺动脉收缩压（PASP）为（44.56±8.25） mm Hg（1 mm Hg＝0.133 kPa）,显著高于无PAH组的（30.28±3.92）mm Hg（P < 0.01）。PAH组与无PAH组每周透析时间、透析间期体质量增加、Hb、Hct、右室横径、右房横径、右房长径和肺动脉内径等指标差异均有统计学意义（P < 0.05）。对以上因素进行Logistic回归分析显示,MHD并发PAH与贫血、透析间期体质量增加和右房横径显著相关（P < 0.05）。 结论　HD患者并发PAH并不少见,60%为轻度PAH,但临床症状隐匿,应提高警惕以早期诊断和早期干预。定期对HD患者行超声心动图检查对筛选PAH非常必要。     

Effects of nutritional parameters on nocturnal blood pressure in patients undergoing hemodialysis

Abstract

Background: Malnutrition is a common problem in uremic patients. It is unclear whether there is an association between the degree of malnutrition and 24-h ambulatory blood pressure patterns in patients undergoing hemodialysis. In the present study, we observed the relationship between the degree of malnutrition and deterioration of the rhythm of diurnal blood pressure, which are both risk factors for cardiovascular morbidity--mortality and associated with hypervolemia. Method: We observed 148 patients undergoing hemodialysis in the Nephrology Department of Celal Bayar University Hospital. All cases were assessed for body weight alterations, dietary food intake, gastrointestinal symptoms, loss of subcutaneous fat and muscle tissue, presence and severity of comorbidities, functional capacity (subjective global assessment), and anthropometric indices. Ambulatory blood pressure measurements were performed for all cases on the day between the two hemodialysis sessions. Results: We found that the circadian blood pressure rhythm deteriorated in patients with a high-malnutrition score, and that malnutrition was more common and severe in those subjects with the non-dipper and reverse-dipper blood pressure patterns. Malnutrition score was positively correlated with the nighttime systolic and nighttime mean blood pressures and mean 24-h arterial blood pressure (all p?≤?0.01). We identified a positive correlation between malnutrition score and the reduction in serum albumin and anthropometric indices. Conclusion: This is the first study to demonstrate an association between malnutrition and deterioration in the circadian blood pressure rhythm in a hemodialysis population. Nutritional disturbance is associated with an increase in night-time blood pressure. Low serum albumin levels and hypervolemia may contribute this situation.