提高透析液钙浓度对透析中低血压患者血流动力学的影响

Effect of higher calcium concentration in dialysate on hemodynamics in intra-dialytic hypotension patients:a cross-over and self-control trial

目的对反复出现透析中低血压的维持性血液透析患者,提高透析液钙浓度,观察透析过程的血流动力学稳定性。方法本研究采用前瞻性、单中心、前后交叉自身对照研究方式,将四川大学华西医院透析中心符合纳入标准的透析中低血压(intra-dialysis hypotension,IDH)患者随机分为2组。A组患者分别予以低钙、中钙、高钙的透析液各进行2周透析,B组患者分别予以高钙、中钙、低钙的透析液各进行2周透析。2组患者均每周透析3次,每次4h。记录透析前与透析过程中的收缩压、舒张压与心率、透析前血压与透析中最低血压差值(△P);记录透析过程中症状性低血压、提前停止透析事件的发生率。结果共有16例IDH患者符合纳入标准,其中2例因发生感染退出,其余14例患者均完成研究。与中钙透析液相比,高钙透析液提高透析过程中的平均收缩压,差别具有显著性差异(F=3.302,P=0.013),而收缩压差值无显著性差异(F=3.047,P=0.098)。与低钙透析液相比,高钙透析液降低透析前与透析中最低血压的收缩压差值有显著性差异(F=3.047,P=0.016),平均收缩压无显著性差异(F=3.302,P=0.073)。而中钙透析液与低钙透析液之间透析中平均收缩压、收缩压差值无显著性差异(分别为F=3.302,P=0.457和F=3.047,P=0.479),但对于舒张压、心率的变化以及减少透析不良事件的发生率无显著作用。结论通过3种钙浓度的比较,高钙透析液对提高透析中低血压患者血流动力学稳定性有一定改善,但不能减少透析中症状性低血压的发生,改善透析充分性。高钙透析液对顽固透析中低血压患者血流动力学方面的作用,尚需要多中心、大样本的临床研究来明确。

Objective Symptomatic intra-dialysis hypotension(IDH) continues to be a common problem.In this study,we investigated the changes in hemodynamic parameters induced by calcium concentration in dialysate in IDH patients.Methods Single-blinded and crossover design was used.Sixteen maintenance hemodialysis patients with IDH were randomized into two groups,beginning by changing the calcium concentration in dialysate either to 1.25mmol/L or 1.75mmol/L.The first 2-week intervention phase was followed by two-week of wash out with calcium concentration in dialysate as 1.5mmol/L,switching round the calcium concentration compared to the initial randomization,by a second 2-week intervention phase.Results Fourteen patients finished the trial,and two patients withdrew due to infection.Compared to lower calcium concentration(1.25mmol/L),dialysate with higher calcium concentration elevated mean intradialytic systolic blood pressure(mSBP)(P<0.05),decreased the maximum difference of SBP(the difference between predialytic SBP and the lowest intradialytic SBP),while the incident of symptomatic IDH and stopping hemodialysis did not decreased significantly.Medium calcium concentration in dialysate did not have any effect on such parameters.Conclusion Higher calcium concentration in dialysate can partially improve the hemodynamic stability in IDH patients.Multiple-centered clinical trial with larger samples is needed.