Indications for aortocoronary shunting in relation to ejection fraction and segmental activity of the left ventricle (data of the coronarography, ventriculography and intra-cardiac hemodynamics)

The left-ventricular ejection fraction, reflecting the contractile capacity of the myocardium according to the clinical data, is the most objective criterion in indication for the operation for aortocoronary shunting. The indices of central hemodynamics appearing in response to the exercise test during intracardiac catheterization of the right heart and monitor-computer control with mathematical analysis were used in objective appraisal of the left-ventricular ejection fraction in selecting for surgical treatment patients suffering from ischemic heart disease with normal and reduced ejection fraction of the left ventricle. Two gradations of patients with ischemic heart disease were set apart during the hemodynamic exercise test: the first--patients with a high and effective chronotropic reserve--subgroup I("+X") and the second--patients with a poor and ineffective chronotropic reserve--subgroup II("--X"). It was found that in a single-valued left-ventricular ejection fraction (normal or low) in patients with ischemic heart disease there may be the presence or absence of latent cardiac insufficiency according to the results of the hemodynamic exercise test which must be determined in indications for surgical treatment.     

Heart failure management in dialysis patients: Many treatment options with no clear evidence

Heart failure with reduced ejection fraction (HFrEF) impacts approximately 20% of dialysis patients and is associated with high mortality rates. Key issues discussed in this review of HFrEF management in dialysis include dialysis modality choice, vascular access, dialysate composition, pharmacological therapies, and strategies to reduce sudden cardiac death, including the use of cardiac devices. Peritoneal dialysis and more frequent or longer duration of hemodialysis may be better tolerated due to slower ultrafiltration rates, leading to less intradialytic hypotension and better volume control; dialysate cooling and higher dialysate calcium may also have benefits. While high-quality evidence exists for many drug classes in the non-dialysis population, dialysis patients were excluded from major trials, and only limited data exist for many medications in kidney failure patients. Despite limited evidence, beta blocker and angiotensin-converting enzyme inhibitor or angiotensin receptor blocker use is common in dialysis. Similarly, devices such as implantable cardiac defibrillators (ICDs) and cardiac resynchronization therapy that have proven benefits in non-dialysis HFrEF patients have not consistently been beneficial in the limited dialysis studies. The use of leadless pacemakers and subcutaneous ICDs can mitigate future hemodialysis access limitations. Additional research is critical to address knowledge gaps in treating maintenance dialysis patients with HFrEF.     

Cardiac function in dialysis patients evaluated by Doppler echocardiography and its relation to intradialytic hypotension: a new index combining systolic and diastolic function

AIM, PATIENTS AND METHODS: Cardiac function of 40 patients on maintenance dialysis was examined using a new Doppler index combining systolic and diastolic function. Immediately before dialysis, ultrasonic pulsed Doppler was used to measure right and left ventricular inflow and outflow waveforms. The sum of the isovolumetric contraction time (ICT) and isovolumetric relaxation time (IRT) was calculated by subtracting the ejection time from the interval between the end of an inflow waveform and the start of the next inflow waveform. The new index was obtained by dividing the sum of the two isovolumetric times by the ejection time. Cardiac function was evaluated in dialysis patients and healthy controls using new indices of the right and left heart systems. RESULT: Indices of the right and left heart systems in dialysis patients were significantly higher than those in healthy controls. With respect to hypotension during dialysis, patients were divided into two groups, a group with decreased blood pressure (group A: 27 patients) and a group with normal blood pressure (group B: 13 patients). Only the left heart system index in group A was significantly higher. There were no significant differences in other M-mode Doppler indices between the two groups. CONCLUSION: The new index was a more sensitive evaluator of cardiac function and predictor of hypotension during dialysis compared to standard echocardiographic indices.     

L-Carnitine in Dialysis Patients

Hemodialysis (HD) patients often have low serum concentrations of free L‐carnitine and decreased skeletal muscle stores. As L‐carnitine is an essential cofactor in fatty acid and energy metabolism, it is possible that abnormal carnitine metabolism in dialysis patients may be associated with clinical problems such as skeletal myopathies, intradialytic symptoms, reduced cardiac function, and anemia. Studies have shown that L‐carnitine supplementation in HD patients improves several complications seen in dialysis patients, including cardiac complications (arrhythmias, reduced output, low cardiothoracic ratio), limitation of exercise capacity, increased intradialytic hypotension, and muscle symptoms. The most promising results have been noted in the treatment of erythropoietin‐resistant anemia. Routine administration of L‐carnitine to all dialysis patients is not recommended at this time; however, a therapeutic trial of L‐carnitine can be useful in symptomatic patients with certain clinical features unresponsive to the usual measures. These include intradialytic muscle cramps and hypotension, asthenia, cardiomyopathy, lowered ejection fraction, muscle weakness or myopathy, reduced oxygen consumption, and anemia requiring large doses of EPO.     

Optimized heart failure therapy and complete anemia correction on left-ventricular hypertrophy in nondiabetic and diabetic patients undergoing hemodialysis

BACKGROUND: According to new guidelines, diabetes mellitus per se can be considered as stage I chronic heart failure (CHF). Available evidence suggests that patients suffering from both diabetes mellitus and renal insufficiency have disproportionately high rates of left-ventricular hypertrophy (LVH). METHODS: Optimized heart failure therapy, including beta-blockers, ACE-inhibitors and AT II-type-1-receptor-blockers, was prescribed in combination with complete anemia correction using epoetin beta (target hemoglobin: 13.5 g/dl for women; 14.5 g/dl for men) to 230 patients (55% male) with ambulatory hemodialysis, including 60 patients (52% male) with diabetes. Echocardiographic follow-up examinations were performed over a mean period of 4.4 +/- 1.2 years. RESULTS: Mean hemoglobin levels at the study end significantly increased to target levels in the entire study population and in patients with diabetes (both p < 0.001). Compared with baseline, significant improvements were seen in hemodialysis patients - both without and with diabetes - in left-ventricular mass index (-28.8 g/m2 [p < 0.001] and 29.0 g/m2 [p < 0.005], respectively), left-ventricular ejection fraction (+7.0% [p < 0.001] and +8.3% [p < 0.01], respectively) and in NYHA class (-0.84 [p < 0.01] and -1.12 [p < 0.01], respectively). Similar to the results in the overall population, a highly significant reduction in LVH (p < 0.005) and significant improvements in LVEF (p < 0.01) and NYHA class (p < 0.01) were seen in the high-risk subgroup of diabetic patients. CONCLUSIONS: Patients undergoing hemodialysis, with or without concomitant diabetes, benefit considerably from optimized, multifactorial heart failure therapy combined with complete anemia correction.     

Left-ventricular performance, volumes, and catecholamine responses during anaesthesia induction--monitoring by combined radionuclide cardiography and right heart catheterization.

Sequential radionuclide imaging and continuous recording of arterial and right heart pressures were carried out during anaesthesia with midazolam 0.2 mg kg-1, pancuronium 0.15 mg kg-1 and fentanyl 10 micrograms kg-1 in eight patients with normal cardiopulmonary status scheduled for craniotomy. The aim was to examine how a stress-free anaesthetic induction tailored to protect against the hypertension and tachycardia provoked by laryngoscopy and intubation influenced left-ventricular performance, left-ventricular loading conditions and plasma catecholamine concentrations. During the 20-min study period no significant changes were observed in heart rate, left-ventricular ejection fraction, ratio of peak systolic pressure to left-ventricular end-systolic volume, pulmonary capillary wedge pressure, left-ventricular end-systolic volume, cardiac output, dopamine and noradrenaline concentrations. Except for a minor increase in mean arterial pressure after laryngoscopy and intubation, mean arterial pressure decreased 24%, left-ventricular end-diastolic volume decreased 15%, and left-ventricular stroke volume decreased 21%. Central venous pressure increased by 75% but there was no parallel increase in pulmonary wedge pressure, which in turn did not reflect the alterations in ventricular end-diastolic volume. Plasma adrenaline concentrations decreased significantly (66%). The chosen induction regimen preserved global left-ventricular pump function during laryngoscopy and intubation without any activation of the sympathetic nervous system. Central venous and pulmonary wedge pressures were unreliable in the assessment of ventricular preload during induction of general anaesthesia.     

Enhanced production of nitric oxide may be involved in acute hypotension during maintenance hemodialysis

To investigate the possible involvement of endogenous nitric oxide (NO) in acute hypotension during maintenance hemodialysis, we measured the plasma concentration of the nitrate anion NO3-, a stable metabolite of NO, in 19 patients undergoing hemodialysis. We analyzed heart rate variability to estimate the relationship between autonomic nervous activity and NO production, low-frequency/high-frequency components (L/H) as a parameter of cardiac sympathetic activity, and high-frequency power as a parameter of cardiac vagal activity. Six patients developed severe hypotension (a change in mean blood pressure during dialysis > or = 20 mm Hg), four patients developed mild hypotension (a change in mean blood pressure < or = 19 mm Hg and > or = 1 mm Hg), and nine patients did not develop hypotension. The plasma levels of NO3- before dialysis were markedly elevated in the severely hypotensive group compared with the patients who showed no hypotension (566+/-122 micromol/L v 133+/-38 micromol/L; P < 0.01), and this difference disappeared midhemodialysis and after hemodialysis. The plasma concentration of NO3- before dialysis was significantly associated with both the change in mean blood pressure during dialysis (r= -0.735; P = 0.003) and the mean blood pressure after dialysis (r = -0.675; P = 0.0015). The L/H ratio was inhibited before or after dialysis in the severely hypotensive group compared with the nonhypotensive group, and hypotension during dialysis was correlated with the inhibited L/H ratio before (r = 0.784; P = 0.001) or after (r = 0.822; P = 0.001) dialysis. Plasma NO3- concentrations were correlated with the L/H ratio before (r = -0.553; P = .014) or after (r = -0.546; P = 0.015) dialysis. These results suggest that inhibited sympathetic activity is one of the causes of acute hypotension during dialysis, and the enhanced production of NO is involved in this inhibition of the sympathetic activity in patients having a hypotensive episode during dialysis. The plasma concentration of NO3- before dialysis may be a predictor of the risk of hypotension during dialysis in patients with end-stage renal disease.     

Failure of arginine-vasopressin and other pressor hormones to increase in severe recurrent dialysis hypotension

BACKGROUND.: Recurrent dialysis hypotension is common in long-term dialysispatients. Argininevasopressin (AVP) is a potent vasoconstrictorhormone, release of which is stimulated in hypotension. STUDY DESIGN.: We measured AVP as well as adrenaline and noradrenaline in 23patients with recurrent dialysis hypotension during severe symptomaticepisodes of dialysis hypotension (BP syst. < 70 mmHg). Wealso tested autonomic function (amyl nitrate inhalation, coldpressor test) during the interdialytic interval. RESULTS.: We observed that systolic blood pressure decreased from 127± 8 (at the end of the first hour of dialysis; takenas control state) to 64 ± 1 mmHg (symptomatic hypotension)in 23 patients. In six of the 23 patients hypotension was accompaniedby nausea, which is a known direct stimulus of AVP. In thesesix patients, plasma AVP showed a large increase; control state,6.2 ± 0.9; hypotension, 130.4 ± 51.1 pg/ml; P< 0.5). Of the remaining 17 patients without nausea, AVPfell moderately in nine and increased in eight. Taken together,this group of 17 hypotensive patients failed to show significantAVP stimulation: control state, 9.0 ± 1.4; hypotension,13.8 ± 3.8 pg/ml, NS). Adrenaline and noradrenaline didnot change during hypotension. During autonomic testing thepatients with recurrent dialysis hypotension (compared to healthycontrols) showed blunted baroreflex response (assessed by amylnitrate inhalation) but intact sympathetic outflow (assessedby cold pressor test). CONCLUSIONS.: The observations of AVP are taken as further evidence of defectsin the afferent rather than the efferent limb of autonomic reflexesin dialysis patients with recurrent dialysis hypotension.     

The heart rate response pattern to dialysis hypotension in haemodialysis patients

BACKGROUND: Hypotension during haemodialysis may be caused by the activation of a cardiovascular reflex causing abrupt sympathetic withdrawal, vasodilatation and bradycardia (bradycardic hypotension). However, the frequency of this type of hypotension is undefined and it is unclear whether or not it underlies a peculiar predisposition to vasodepressor syncope. OBJECTIVE: To assess the prevalence of bradycardic hypotension and to test the hypothesis that dialysis patients are predisposed to vasodepressor syncope. RESULTS: Sixty hypotensive episodes were recorded in 20 patients (> or = 2 episodes in 15 patients). Heart rate increased in 35 episodes, did not change in 19 episodes and decreased in six episodes. The HR response pattern to hypotension was reproducible in 10 patients (always tachycardia, 6; always unchanged heart rate 4). Patients developing bradycardic hypotension (n = 5) all had an erratic HR response to hypotension (i.e. bradycardia preceded or followed by tachycardia or by no HR change) and were characterized either by the typical haemodynamic pattern of hypovolaemia (predialysis hypotension, tachycardia and low TBW) or by being treated with a very high UF rate (> 0.3 ml/kg/min). Post-dialysis echocardiography showed that the LVEDD was less (one-tailed P = 0.055) in patients with bradycardic hypotension than in those with tachycardic responses or with unchanged HR. On tilt testing (after dialysis) three of 11 (27%) dialysis hypotensive patients developed bradycardic hypotension. This proportion was identical to that expected in healthy subjects and in control patients without syncope. CONCLUSIONS: Tachycardia is the more frequent heart rate response to dialysis hypotension in uraemic patients. Bradycardic hypotension in dialysis patients is associated with a haemodynamic profile indicating a more severe degree of cardiovascular underfilling. Bradycardic hypotension probably represents a physiological response to hypovolaemia rather than the expression of a peculiar predisposition to vasodepressor syncope.      

A comparison of hemodynamic indices derived by invasive monitoring and two-dimensional echocardiography

Intraoperative two-dimensional echocardiography (2D-echo) is useful for monitoring global and regional left ventricular function. The 2D-echo view most frequently utilized during intraoperative monitoring is the short-axis view at the level of the papillary muscles. To determine whether hemodynamic data can be derived from this single 2D-echo short-axis view, 12 patients undergoing coronary artery bypass grafting (CABG) were studied. All patients had normal left-ventricular function preoperatively (ejection fraction = 64% +/- 12%). Echo-data were obtained before and after cardiopulmonary bypass (CPB) by epicardial placement of a 5 MHz echo-transducer. The correlation between thermodilution and echo-derived cardiac indices was good (r = 0.8), and not significantly different from the correlation between stroke indices (r = 0.68). A strong positive correlation was established between end-diastolic volume index and echo cardiac index (CIE) (r = 0.93 before CPB; r = 0.91 after CPB) and end-diastolic area index and CIE (r = 0.94 before CPB; r = 0.91 after CPB). The pulmonary capillary wedge pressure was not a determinant of cardiac index before or after cardiopulmonary bypass. No correlation was observed between systemic vascular resistance and echo-derived wall stress. These findings demonstrate that, in patients with good left-ventricular function undergoing CABG surgery, 2D-echo provides a better index of left-ventricular preload than conventional invasive hemodynamic monitoring.     

Factors associated with hypotension and bradycardia after carotid angioplasty and stenting

BACKGROUND: Acute procedurally induced hemodynamic depression can occur after carotid angioplasty and stenting (CAS). This study was performed to determine the frequency and risk factors for hypotension and bradycardia after the CAS procedure. METHODS: The study reviewed clinical variables and angiographic data of all patients undergoing elective CAS with neuroprotection during a recent 5-year period. Intravenous atropine was given selectively in cases of bradycardia (heart rate <60 beats/min or a decrease of >20 beats/min). We further defined hemodynamic depression as bradycardia or severe hypotension (systolic blood pressure fall >30 mm Hg). Frequency and potential risk factors for hemodynamic depression were analyzed by logistic regression. RESULTS: During the study period, 416 patients (99% male; mean age, 74 +/- 11 years) underwent the CAS procedure. The median degree of stenosis was 93% (range, 60% to 99%). The frequencies of post-CAS hemodynamic depression include hypotension in 58 (14%), bradycardia in 112 (27%), or both in 21 (5%). All patients with bradycardia received intraprocedural atropine, and all heart rates returned to the baseline level. Persistent hypotension occurred in 45 patients (11%). Increased age was associated with CAS-induced bradycardia or hypotension. Adjusted risk factors associated with hemodynamic depression include age >78 years (odds ratio [OR], 5.25; 95% confidence interval [CI], 2.32 to 15.25; P = .01) and ejection fraction of <25% (OR, 3.25; 95% CI, 0.58 to 6.58; P = .02). CEA-related restenosis was associated with a reduced risk of hemodynamic depression (OR, 0.21; 95% CI, 0.12 to 0.69, P = .001). Persistent hypotension after CAS was associated with an increased risk of an adverse clinical event (44%, P = .001). CONCLUSIONS: Hemodynamic depression, including hypotension and bradycardia, is frequent after CAS. However, CAS-induced hemodynamic depression is rare in patients with postendarterectomy stenosis. Patients with compromised ejection fraction and increased age are at a higher risk of presenting with CAS-induced hemodynamic instability, and persistent hypotension after CAS is associated with an increased postprocedural complication rate.     

Treatment of dialysis-induced hypotension with L-threo-3,4-dihydroxyphenylserine

L-threo-3,4-dihydroxyphenylserine (L DOPS), a precursor of noradrenaline(norepinephrine), which is converted into noradrenaline whenorally administered, was given orally to haemodialysed patientsexhibiting dialysis-induced hypotension. In five patients given300 mg L-DOPS plasma concentrations reached a peak of 1.43 ±0.59µg/ml 6 h after administration and decreased slowly todisappear after 36 h. Plasma noradrenaline concentrations showeda significant increase (P <0.05), reaching a peak of 1.28±0.64ng/ml after 24 h and declined to 0.75 ±0.47 ng/ml by48 h. Administration of L-DOPS to six patients during dialysisfor 6 consecutive weeks showed no accumulation in the blood.Oral administration of 200–400 mg L-DOPS to 34 patients1 h before dialysis prevented dialysis-induced hypotension anddecreased the number of concurrent treatments required for hypotension.The signs and symptoms of hypotension were improved in 73.5%of the patients and persisted after dialysis in 64.7%. The preventiveeffect of L-DOPS was significantly more prominent in patientswith predialysis systolic blood pressure less than 100 mmHgand in patients with non-diabetic nephropathy. L-DOPS appearedto be an effective and well- tolerated treatment for the preventionof dialysis-induced hypotension.     

Myocardial contractility does not determine the haemodynamic response during dialysis.

BACKGROUND: LV systolic dysfunction in dialysis patients has been implicated in the genesis of dialysis hypotension. End-systolic elastance (E(es)), a relatively load-independent parameter of myocardial contractility, was assessed by testing the acute left ventricular (LV) response to nitroglycerine (NTG) in hypotension-prone (HP) and hypotension-resistant (HR) patients. METHODS: Routine measurement of ejection fraction (EF) was done before dialysis in 15 patients without significant valvular disease or symptoms of coronary heart disease. Continuous arterial pressure was measured by Finapres, with systolic blood pressure (SBP) as surrogate for LV end-systolic pressure. Simultaneously, LV area was measured using automated border detection. SBP and LV area data were combined online to create pressure-area loops in real time following intravenous NTG bolus. E(es) was determined offline by beat-to-beat analysis of consecutive pressure-area loops. RESULTS: SBP, at baseline 168 mmHg (128-188 mmHg), decreased to 127 mmHg (79-161 mmHg). End-systolic LV area, at baseline 6 cm2 (1-12 cm2), decreased to 4 cm2 (1-10 cm2). E(es) in the HP group (11 mmHg cm(-2); 7-22 mmHg cm(-2)) was not different from E(es) in the HR group (9 mmHg cm(-2); 4-16 mmHg cm(-2)). EF was 61% (45-73%). There was no correlation between E(es) and EF. CONCLUSIONS: In this population of dialysis patients without clinically manifest heart disease, the HP and HR groups had a similar E(es). Therefore, these two types of dialysis patients were not distinguished by a difference in myocardial contractility. The results of this study argue against a role for reduced myocardial contractility in the genesis of intradialytic hypotension.     

Serum chromogranin A concentration and intradialytic hypotension in chronic haemodialysis patients

Aim The aim of this study was to investigate the influence of haemodialysis on plasma chromogranin A (CgA) concentration and to assess the relationship between CgA, blood pressure, occurrence of intradialytic hypotension episodes and residual renal function, respectively. Methods The study included 38 chronic haemodialysis patients (24 M, 14 F; mean age 56.2 ± 13.6 years). Plasma CgA and blood pressure were measured before and after a mid-week dialysis. Control group included 10 age- and sex-matched healthy subjects. Results Plasma CgA levels were on average 50-fold higher in HD patients than in the controls (699 ± 138 vs. 14 ± 6 U/L). In HD patients plasma CgA corrected for ultrafiltration rates significantly increased (to 836 ± 214 U/L, P < 0.001) at the end of dialysis procedure. In patients with (n = 8) and without frequent symptomatic intradialytic hypotension episodes predialysis values of CgA were similar (701 ± 169 vs. 698 ± 132 U/L) but post-dialysis were significantly lower in the former group (746 ± 312 vs. 860 ± 177 U/L; P = 0.03) despite a similar rate of ultrafiltration (2675 ± 1009 and 2583 ± 1311 ml, respectively). Accordingly, in patients with intradialytic hypotension an increase of plasma CgA during dialysis was also much lower than in patients without hypotension (45 ± 81 vs. 163 ± 144 U/L; P = 0.001). Conclusions CgA undergoes marked accumulation in renal failure. The increase of plasma CgA during dialysis is impaired in subjects with intradialytic hypotension episodes, which confirms the role of autonomic dysfunction in the pathogenesis of this complication.     

Association of Mortality Risk with Various Definitions of Intradialytic Hypotension

Intradialytic hypotension is a serious and frequent complication of hemodialysis; however, there is no evidence-based consensus definition of intradialytic hypotension. As a result, coherent evaluation of the effects of intradialytic hypotension is difficult. We analyzed data from 1409 patients in the HEMO Study and 10,392 patients from a single large dialysis organization to investigate the associations of commonly used intradialytic hypotension definitions and mortality. Intradialytic hypotension definitions were selected a priori on the basis of literature review. For each definition, patients were characterized as having intradialytic hypotension if they met the corresponding definition in at least 30% of baseline exposure period treatments or characterized as control otherwise. Overall and within subgroups of patients with predialysis systolic BP<120 or 120–159 mmHg, an absolute nadir systolic BP<90 mmHg was most potently associated with mortality. Within the subgroup of patients with predialysis BP≥160 mmHg, nadir BP<100 mmHg was most potently associated with mortality. Intradialytic hypotension definitions that considered symptoms, interventions, and decreases in BP during dialysis were not associated with outcome, and when added to nadir BP, symptom and intervention criteria did not accentuate associations with mortality. Our results suggest that nadir-based definitions best capture the association between intradialytic hypotension and mortality.     

Autonomic nervous system dysfunction and volume nonresponsive hypotension in hemodialysis patients

Studies were conducted in 9 dialysis patients with volume-nonresponsive hypotension, 6 dialysis patients with volume-responsive hypotension and in 10 normal subjects in an effort to evaluate the role of dysfunction of the autonomic nervous system (ANS) in the genesis of volume-nonresponsive hypotension. ANS function was evaluated by the Valsalva maneuver, handgrip exercise, and by the response of heart rate and blood pressure to change of posture from a supine to a standing position. Patients with volume-nonresponsive hypotension displayed significant derangements in the function of ANS as compared to normal subjects and to patients with volume-responsive hypotension. Data show that dysfunction of ANS plays an important role in the genesis of volume-nonresponsive hypotension in dialysis patients.     

Advantages of bicarbonate hemodialysis

Six patients with frequent episodes of symptomatic hypotension during acetate dialysis were treated with bicarbonate dialysis. In all patients blood pressure, heart rate, and arterial acid-base values were measured every 30 minutes during each of the five treatments with acetate dialysis and bicarbonate dialysis. Hemodynamic parameters were measured invasively in all patients during bicarbonate dialysis and in three of them also during acetate dialysis. Additionally, continuous long-time monitoring with electroencephalography was performed during acetate dialysis and bicarbonate dialysis. During acetate dialysis the patients showed a frequent onset of sudden hypotension and arrhythmia with concomitant symptoms of the so-called disequilibrium syndrome, whereas these symptoms were nonexistent in the same patients during bicarbonate dialysis.     

缓慢低效透析滤过对维持性血液透析患者低血压状态的影响

目的探讨应用持续缓慢低效每日透析滤过（SLEDI）-f）对于维持性血液透析（MHD）患者合并低血压状态的临床治疗效果。方法选择我院血液净化中心合并低血压状态的MHD患者36例,应用SLEDI）-f治疗,观察每次治疗过程中患者生命体征指标（血压、脉搏、心率、体温）、血氧饱和度,记录总超滤量、尿素氮和血肌酐变化并计算尿素清除指数（Kt／V）;整个疗程治疗前、后行彩色多普勒超声检测心功能指标,同时监测C反应蛋白（CRP）。结果治疗过程中,患者生命体征稳定,并发症少,透析充分性好。治疗后,患者左心室舒张末期内径（LVDd）较治疗前降低（P〈0．05）,心脏指数（CI）及左心室射血分数（LVEF）较治疗前升高（P〈0．05）,CRP较治疗前降低（P〈0．01）。结论采用SLEDI）-f治疗可提高MHD合并低血压状态患者对治疗的适应性,显著改善心功能指标,有助于提高患者治疗效果。     

序贯透析联合低温可调钠透析对透析相关性低血压的临床应用研究

目的 探讨序贯透析联合低温可调钠透析对透析相关性低血压的治疗作用.方法 21例透析相关性低血压患者采用前瞻性交叉设计方法,先后采取标准常温常规透析、低温可调钠透析、序贯透析、序贯透析联合低温可调钠透析等4种不同透析模式,每人每种透析模式实施3周.观察各组患者体质量改变、超滤量,透后血肌酐、尿素氮、血钾、血钠,透析中最低血压并计算平均动脉压(MAP),透析相关性低血压发作次数、发生时间和需要的护理干预措施.结果 序贯透析联合低温可调钠透析组低血压的发生率较常规透析组显著降低,较序贯透析组和低温可调钠透析组明显降低;4种透析模式对患者的溶质清除,调节透后血钾、血钠,均无统计学差异.结论 序贯透析联合低温可调钠透析能较好地预防透析相关性低血压的发生,不影响透析效果,操作简便易行.     

Early and late outcomes of coronary artery bypass surgery versus percutaneous coronary intervention with drug-eluting stents for dialysis patients

Abstract Background: Advances in percutaneous coronary intervention (PCI) using drug‐eluting stents (DES) have impacted clinical practice. However, the efficacy of DES for dialysis patients still remains controversial. This study compares the early and long‐term clinical outcomes of coronary artery bypass grafting (CABG) and PCI with DES in dialysis patients. Methods: A retrospective review was performed in 125 dialysis patients treated between 2004 and 2007. Fifty‐eight patients underwent CABG and 67 underwent PCI with DES. The overall death, cardiac death, and cardiac‐related event rates were analyzed using the Kaplan‐Meier method. For the risk‐adjusted comparisons, multivariable logistic and Cox regression analyses were used. Results: The preoperative characteristics of the patients were similar except for the ejection fraction (p = 0.002) and the number of diseased vessels (p < 0.001). The 30‐day mortality was 0 in both groups. The overall survival rates at one, three, and five years were 84.2%, 64.7%, and 56.2% in CABG group and 88.2%, 75.5%, and 61.7% in DES group, respectively (p = 0.202). The rates of freedom from cardiac‐related events at one, three, and five years were 76.6%, 68.1%, and 48.6%, and 63.0%, 31.4%, and 0% in CABG and DES groups (p < 0.001), respectively, including seven (10%) late thromboses in the DES group. Although the risk‐adjusted analysis showed no significant difference for overall and cardiac death rates, the rates of cardiac‐related events and graft/stent failure were significantly higher in the DES group. Conclusions: CABG is superior for revascularization in dialysis patients compared with PCI using DES in terms of freedom from cardiac‐related events. (J Card Surg 2012;27:281‐287)