维持性血液透析患者透析中血压变异性的相关因素及其对预后的影响

目的 评估维持性血液透析(MHD)患者透析过程中血压变异性(BPV)情况,探讨影响MHD过程中BPV增加的相关危险因素,了解其与预后的关系.方法 对2009年1月1日以前开始在上海交通大学附属第一人民医院常规透析的MHD患者行回顾性分析.记录2009年1月-2010年12月期间每季度第1次血液透析过程中所有血压值,求取收缩压、舒张压的平均值和标准差,以离散系数表示透析中收缩压和舒张压BPV.随访时间未满2年的患者取时间平均分布的6～8个透析过程的血压计算.记录心血管事件及死亡,继续随访至2011年12月31日.结果 共纳入280例患者.平均透析中收缩压BPV为0.119 ±0.029,舒张压BPV为0.118 ±0.028;其中老年MHD患者(114例)透析中收缩压的BPV显著高于青中年组(166例)(0.126±0.029比0.114 ±0.028,P=0.012),两组间透析中舒张压的BPV差异无统计学意义(0.117±0.031比0.119 ±0.025,P=0.498).将透析中收缩压BPV作为应变量进行多元回归分析,结果显示患者年龄、透析前收缩压、透析间期体重增长率及血红蛋白水平是透析中收缩压BPV的独立影响因素.将透析中舒张压BPV作为应变量进行多元回归分析,结果显示透析间期体重增长率、平均脱水量是透析中舒张压BPV的独立影响因素.随访3年,死亡64例(22.9％),生存分析显示透析中收缩压BPV升高与病死率升高显著相关(P＜0.01).结论 高龄、透析前高收缩压、透析间期体重增长率增加、血红蛋白水平降低为MHD患者透析中收缩压BPV升高的独立危险因素,透析间期体重增长率增加为MHD患者舒张压BPV升高的独立危险因素,透析中收缩压的BPV升高与MHD患者全因死亡率增加有关.

Related factors and prognostic significance of intradialytic blood pressure variability in patients on maintenance hemodialysis

Objective To evaluate intradialytic blood pressure variability (BPV) in patients on maintenance hemodialysis (MHD), and to investigate the correlated factors of BPV in MHD process and its correlation with prognosis.Methods Patients with end stage renal disease on MHD before January 1, 2009 were enrolled and analyzed retrospectively. Blood pressure at the first hemodialysis every quarter during January, 2009 and December, 2010 were recorded. The systolic pressure, diastolic pressure were calculated, and dialysis systolic and diastolic BPV were expressed with discrete coefficients. As for patients with follow-up time less than 2 years, blood pressures in evenly distributed 6-8 courses were used for calculation.Cardiovascular events and death were recorded and the follow-up was lasted till December 31, 2011.Results A total of 280 patients were enrolled, with intradialytic systolic BPV of 0.119±0.029, and intradialytic diastolic BPV of 0.118±0.028. Intradialytic systolic BPV in the elderly group (n=114) was significantly higher than that in the younger group (n=166) (0.126±0.029 vs 0.114±0.028, P=0.012), while no significant difference was found in diastolic BPV (0.117±0.031 vs 0.119±0.025, P=0.498). Intradialytic systolic BPV was used as variates in multivariable regression analysis, and results showed that age, systolic blood pressure before dialysis, interdialytic weight gain (IDWG) rate during dialysis and hemoglobin level were independent influential factors for intradialytic systolic BPV. The intradialytic diastolic BPV was used as variates in multivariable regression analysis, and results showed that IDWG rate and average dehydration volume were independent influential factors for intradialytic diastolic BPV.During 3 years of follow-up, 64 patients died (22.9%). The survival analysis showed that the dialysis systolic BPV elevation was associated with the mortality rate (P<0.01).Conclusions Older age, high systolic pressure before hemodialysis, high IDWG rate, and low hemoglobin level were independent risk factors of high intradialytic systolic BPV increase. Intradialytic high IDWG is an independent risk factor of high intradialytic diastolic BPV increase in patients on MHD. Intradialytic systolic BPV increase is associated with all-cause mortality in patients on MHD