维持性血液透析患者透析过程中发生有效血容量不足时血压波动特征及其与透析开始时血压的比较

目的探讨慢性肾功能衰竭患者在血液透析超滤治疗过程中引发的有效血容量不足临床症状,对症状形成时的血压变化进行临床分析。方法选取2016年10月至2019年2月在阳泉煤业(集团)有限责任公司总医院肾内科维持性血液透析患者146例,共进行39658例次血液透析。发生可确定的血容量不足出现的临床症状病例3527例次。分析透析早期(>0~≤60 min)、中期(>60~≤180 min)、后期(>180~≤240 min)各时间段发生血容量不足时的临床症状特点。对透析中的低血压、高血压、维持血压进行定义,统计临床症状出现时各种血压发生率。将临床症状出现时测得的平均动脉压(mean arterial pressure,MAP)与其透析开始时的MAP进行比较,对MAP的演变过程进行分类。对透析间期干体质量增加量即≥5%或<5%在透析超滤中引发临床症状的发病情况给予统计。分析透析中超滤过速、过量外的其他导致血容量不足临床症状的因素。结果血容量不足出现的临床症状发生率为8.9%(3527/39658)。有效血容量不足引发的临床症状在透析的各时间段均有表现,有其发病特点。血压指标不能准确反映临床症状发生必有的相关联性。透析>0~≤60 min发生的有效血容量不足多与超滤量过多、过快有关,共发病493例次,其中低血压341例次,占69.1%(341/493);高血压79例次,占16.1%(79/493);维持血压73例次,占14.8%(73/493)。透析>60~≤180 min,临床症状发生率增加,与持续或过量超滤有关,共发病1306例次,其中低血压1003例次,占76.8%(1003/1306);高血压179例次,占13.7%(179/1306);维持血压124次,占9.5%(124/1306)。透析>180~≤240 min是临床症状的高发时间段,与持续的超滤并超出干体质量设置有关,共发病1728例次,其中低血压1408例次,占81.5%(1408/1728);高血压发生减少,但仍有顽固性高血压病例。血容量不足临床症状出现时,1989例次表现为渐降型低血压,容易引起临床关注;763例次表现为骤降型低血压,临床症状出现前血压较稳定,出现时血压骤然下降;446例次临床症状出现时较透析前有明显升高,给临床症状的判断带来困难;329例次维持了透析前的血压。过度水潴留在全程透析临床症状均有发作,总次数显著增多。一般水潴留发生次数少,多发生于透析>180~≤240 min。血浆胶体和晶体渗透压影响血浆再充盈,透析超滤方式的改变以及透析温度对血压和血容量变化有影响。结论慢性肾功能衰竭血液透析治疗的患者,因其发病特点和治疗的特殊性,透析超滤过程易发生有效血容量不足引起的相关临床症状。而临床症状的出现并不与血压变化同步,提高对血容量不足临床症状认识,做到早发现、早处置,有利于后续血液透析的安全治疗,较好的完成超滤目标值。

Characteristics of blood pressure fluctuation in hemodialysis patients with insufficient effective blood volume and comparison with blood pressure at the beginning of hemodialysis

Objective To explore the clinical symptoms of effective blood volume deficiency caused by ultrafiltration in hemodialysis patients with chronic renal failure,and to analyze the changes of blood pressure during the formation of symptoms.Methods From October 2016 to February 2019,146 patients with maintenance hemodialysis were selected from the Yangquan coalmine group General Hospital for 39658 hemodialysis.There were 3527 cases of clinical symptoms of definable hypovolemia.The characteristics of clinical symptoms in the early stage of dialysis(>0-≤60 min),medium(>60-≤180 min)and late(>180-≤240 min)were analyzed.To define the hypotension,hypertension and maintenance blood pressure in dialysis,and to count the incidence of various blood pressure when clinical symptoms appear.The mean arterial pressure(mean arterial pressure,MAP)measured at the onset of the disease was compared with(MAP)at the onset of dialysis,and the evolution of(MAP)was classified.The dialysis interval weight gain≥5%or<5%,was counted for the onset of the condition caused by dialysis ultrafiltration.To analyze the clinical symptoms of hemodialysis caused by ultrafiltration speed and excess.Results The incidence of clinical symptoms was 8.9%(3527/39658).The clinical symptoms caused by the insufficiency of effective blood volume are manifested in each period of dialysis,and have the characteristics of disease.Blood pressure index can not accurately reflect the correlation of clinical symptoms.There were 493 cases of effective blood volume deficiency during dialysis>0-≤60 min.Among them,341 cases of hypotension,accounting for 69.1%(341/493),79 cases of hypertension,accounting for 16.1%(79/493),73 cases of maintaining blood pressure,accounting for 14.8%(73/493).The incidence of clinical symptoms was increased when dialysis was>60-≤180 min,which was related to continuous or excessive ultrafiltration.There were 1306 cases in total,including 1003 cases of hypotension,accounting for 76.8%(1003/1306);179 cases of hypertension,accounting for 13.7%(179/1306);124 times of maintaining blood pressure,accounting for 9.5%(124/1306).Dialysis>180-≤240 min is the high incidence period of clinical symptoms,which is related to continuous ultrafiltration and exceeding the setting of dry body mass.There are 1728 cases in total,including 1408 cases of hypotension,accounting for 81.5%(1408/1728);hypertension is reduced,but there are still cases of stubborn hypertension.When the clinical symptoms of hypovolemia occurred,1989 cases were hypotension,which was easy to attract clinical attention;763 cases were hypotension,which was stable before the clinical symptoms appeared,and then the blood pressure dropped suddenly;446 cases were significantly higher than before the clinical symptoms appeared,which made it difficult to judge the clinical symptoms;329 cases maintained the blood before the dialysis pressure.Excessive water retention in the whole process of dialysis has clinical symptoms,the total number of times increased significantly.The incidence of common water retention was less than that of dialysis>180-≤240 min.The osmotic pressure of plasma colloid and crystal affects the refilling of plasma,the change of ultrafiltration mode and the change of dialysis temperature on blood pressure and blood volume.Conclusion Because of the characteristics of the disease and the particularity of the treatment,the hemodialysis ultrafiltration process is prone to the related clinical symptoms caused by insufficient effective blood volume.However,the occurrence of clinical symptoms is not synchronous with the change of blood pressure.To improve the understanding of clinical symptoms of insufficient blood volume,to achieve early detection and early treatment is conducive to the safe treatment of follow-up hemodialysis and better completion of ultrafiltration target value.