个体化治疗模式对高血压维持性血液透析患者居家血压变异度的影响

目的 了解高血压血液透析（hemodialysis,HD）患者居家血压变异度状况,并观察根据HD患者高血压发病机制进行个体化治疗后,HD患者居家血压变异度的变化情况.方法 选取北京朝阳医院肾内科透析室部分稳定维持性HD患者进行家庭血压（Home-BP）监测,了解HD患者居家血压变异度情况,以居家血压的变异系数表示血压变异度.并以家庭收缩压≥150mmHg （1mmHg=0.133kPa）为未控制的高血压的诊断标准,对未控制的高血压患者进行生物电阻抗监测、透析前后血清钠测定、药物使用情况调查,了解水、钠负荷及药物应用合理性情况,进而针对性地分别进行降低干体质量、应用低钠透析液和合理使用降压药物的干预措施.随访2个月,观察患者血压及血压变异度情况. 结果 共有105例稳定维持HD患者进行家庭血压监测,患者居家血压变异度为（4.8±2.2/5.0±2.4）％.未控制的高血压患者有60例（57.1％）,经个体化降压治疗后,居家血压从（166.3±12.6/87.5±11.7） mmHg降至（154.1±14.2/82.6±11.4）mmHg（P＜0.001,t=7.223; t=4.796,P＜0.001）,收缩压变异度由（4.9±2.2）％降至（4.6±2.5）％ （P=0.340,t=0.961）.其中30例容量超负荷患者,予降低干体质量后,家庭收缩压和舒张压明显降低,变异系数分别下降0.4％和0.1％（P=0.027,t=2.329;P=0.041,t=2.138）.12例患者应用低钠透析液（136mmol/L）后,居家血压下降,血压变异度无明显改变.其余18例容量负荷正常、未使用低钠透析的患者通过增加肾素-血管紧张素抑制剂和αβ受体阻滞剂等,居家血压下降,血压变异度减小,但未达统计学差异.结论 针对高血压HD患者高血压的病因进行治疗,能够有效地改善患者的家庭血压及血压变异度.

Effect of individualized intervention on home blood pressure and blood pressure variability in maintenance hemodialysis patients with hypertension

Objective To investigate home blood pressure variability and to observe the effect of individualized intervention on home blood pressure variability in maintenance hemodialysis （MHD） patients with hypertension.Methods Home blood pressure was monitered in stable MHD patients in our hospital.The coefficient of variation （CV） was used as the indicator for home blood pressure variability.Home systolic blood pressure ≥150 mmHg was defined as uncontrolled hypertension.Patients with uncontrolled hypertension were subject to bioimpendance assay,serum sodium measurement,and evaluation of antihypertensive treatment,and were used the individualized intervention including decrease of dry body weight,negative sodium gradient dialysis and adjustment of antihypertensive agents.They were followed up for home blood pressure and blood pressure variability for 2 months.Results A total 105 MHD patients were subjected to home blood pressure monitoring.The average CV for home blood pressure variability was 4.8±2.2/5.0±2.4％.Sixty of the 105 patients （57.1％） were identified to have uncontrolled hypertension.After the individualized intervention,home blood pressure decreased from 166.3± 12.6/87.5 ± 11.7 mmHg to 154.1 ± 14.2/82.6± 11.4 mmHg （t=7.223,P＜0.001; t=-4.796,P＜0.001）,home systolic blood pressure variability decreased from 4.9±2.2％ to 4.6±2.5％.In the 30 overhydrated patients,dry body weight reduced under the guidance of bioimpedance technique,accompanied by significant decreases of home blood pressure,CV of home systolic and diastolic blood pressure variability （0.4％ and 0.1％） and dose of antihypertensive agents.Twelve uncontrolled hypertensive patients were subject to negative sodium gradient dialysis,resulting in significant decrease of home blood pressure but without change in home blood pressure variability.In the remaining 18 uncontrolled hypertensive patients,re-adjustment of antihypertensive drugs decreased home blood pressure but without significant change in CV of home blood pressure variability.Conclusions Individualized intervention can improve home blood pressure control and blood pressure variability.