氨基末端脑钠肽前体预测血液透析患者透析中低血压的发生

目的 研究维持性血液透析(MHD)患者透析中低血压(IDH)发生的危险因素,分析血氨基末端脑钠肽前体( NT-proBNP)水平与IDH发病的关系,为防治提供依据.方法 收集2009年3月至5月我院肾内科血液净化中心202例MHD患者资料,根据3个月内每次血透中血压下降情况,分为无透析中低血压组( no-IDH)、透析中低血压偶发组(o-IDH)和透析中低血压频发组(f-IDH).IDH指透析中收缩压下降≥20 mm Hg,或平均动脉压降低≥10 mm Hg并有低血压症状或需要干预措施.3个月透析过程中发生IDH频率＜1/10为no-IDH,≥1/10但≤1/3为o-IDH,＞1/3为f-IDH.应用多因素Logistic回归分析各指标与IDH发生相关性.血NT-proBNP诊断效能用受试者工作特征(ROC)曲线下面积(AUC)评价.结果 202例MHD患者中男108例(53.5％),女94例(46.5％),年龄20～80( 55.85±14.48)岁.原发病分别为肾小球肾炎133例(65.8％)、糖尿病肾病20例(9.9％)、高血压肾病17例(8.4％).IDH发病率42.1％,其中o-IDH 27.2％,f-IDH 14.9％.多因素Logistic回归分析显示年龄、性别、超滤率、血NT-proBNP、血浆白蛋白、主动脉根部内径等与IDH发生密切相关(均P＜ 0.05).血NT-proBNP水平与透析初始血压及透析中血压下降值均呈正相关(P＜0.05).以血NT-proBNP水平判断MHD患者发生IDH的AUC为0.76(95％ CI 0.69～0.83,P＜0.01)；以NT-proBNP 1746.5 ng/L作为界值的灵敏度为88.61％,特异度为51.10％.判断MHD患者频发IDH的AUC为0.65(95％ CI 0.53～0.76,P＜0.05),以NT-proBNP 8208.0 ng/L作为界值的灵敏度为33.33％,特异度为91.30％.结论 高龄、女性、高超滤率、高血NT-proBNP水平、低血浆白蛋白、主动脉根部内径短是MHD患者发生IDH的主要危险因素.血NT-proBNP可作为IDH发病的预测因子.

NT-proBNP as a predictor of intradialytic-hypotension among maintaining hemodialysis patients

Objective To assess the risk factors of intradialytic-hypotension (IDH) among maintaining hemodialysis (MHD) patients and to explore the relation between NT-proBNP and IDH, thus to provide clinical evidence for the prevention and treatment of IDH. Methods A total of 202 MHD patients during March 2009 to May 2009 in our dialysis center were enrolled in the study. Intradialytic blood pressure (BP) was measured during a 3-month period. IDH was defined as an event characterized by a sudden drop in systolic BP more than 20 mm Hg or in mean artery pressure (MAP) more than 10 mm Hg. Logistic regression analysis was used to assess the risk factors of IDH. ROC curve was used to evaluate the diagnostic efficacy of serum NT-proBNP. Results The incidence of IDH was 42.1%. One hundred and seventeen patients with no-IDH (<1/10 hypotensive events per 3 months) were served as controls. Fifty-five patients with o-IDH (≥1/10 but ≤1/3 hypotensive events per 3 months) and 30 patients with f-IDH (＞1/3 hypotensive events per 3 months) were identified among 202 patients. Multivariate regression analysis showed that age, gender, ultrafiltration rate, serum NT-proBNP, serum albumin, aortic root dimension (AoRD) were associated with IDH among MHD patients. Serum NT-proBNP was positively correlated with IDH. The area under the ROC curve (AUC) of NT-proBNP was 0.76 (95% CI 0.69 to 0.83, P<0.01). The cut-off value of serum NT-proBNP for IDH was 1746.5 ng/L, with a sensitivity of 88.61% and a specificity of 51.10%. Furthermore, the AUC of NT-proBNP for f-IDH was 0.65 (95% CI 0.53 to 0.763, P<0.01). The cut-off value of serum NT-proBNP for f-IDH was 8208.0 ng/L, with a sensitivity of 33.33% and a specificity of 91.30%. Conclusions Elderly, female, high ultrafiltration rate, high level of serum NT-proBNP, hypoalbuminemia, shorter AoRD are independent risk factors of IDH among MHD patients. Serum NT-proBNP can be used as a predictor of IDH.