维持性血液透析患者透析中低血压的危险因素研究

A study on the risk factors for intradialytic-hypotension among maintenance hemodialysis patients

目的阐明维持性血液透析(maintenance hemodialysis MHD)患者透析中低血压(intradialytic-hypotension,IDH)发生的危险因素,为防治提供依据。方法收集2009年1月～2010年12月复旦大学附属中山医院肾内科血液净化中心293例MHD患者资料,根据3个月内每次血液透析中血压下降情况,分成无透析中低血压组(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>20mmHg(1mmHg=0.133kpa)或平均动脉压降低≥10mmHg,并有低血压症状。3个月透析过程中发生IDH的频率<1/10定义为no-IDH,≥1/10但≤1/3为o-IDH,>1/3为f-IDH。应用多因素Logistic回归分析各个指标与透析中低血压发生的相关性。结果 293例MHD患者入组,其中男性180例(61.4%)、女性113例(38.6%),年龄56.57±4.54(49～68)岁。终末期肾病原发病因中肾小球肾炎194例(66.2%)、糖尿病肾病30例(10.2%)、高血压肾病24例(8.2%)。透析中低血压的发病率39.9%,其中o-IDH为27.3%,f-IDH为12.6%。以超滤量/体质量水平判断MHD患者发生透析中低血压的AUC为0.706(95%CI:0.64～0.77,P<0.01),以超滤量/体质量4.33%作为界值的灵敏度为53.2%,特异度为76.5%。多因素Logistic回归分析结果显示年龄、超滤率、血NT-proBNP、血浆白蛋白、血2微球蛋白(2MG)等指标与透析低血压发生密切相关(P<0.05)。结论高龄、高超滤率、血NT-proBNP水平高、血2MG水平高、低血浆白蛋白是维持性血液透析患者发生透析中低血压的独立危险因素。

Objective To assess the risk factors for intradialytic-hypotension (IDH) among maintenance hemodialysis (MHD) patients and to provide clinically useful information for the prevention and treatment of IDH. Methods We recruited 293 patients who underwent hemodialysis during Jan. 2009 to Dec. 2010. Intradialytic blood pressure was monitored in a 3-month period. IDH was defined as an event characterized by a sudden drop of systolic BP more than 20mmHg or of mean artery pressure (MAP) more than 10mmHg. Logistic regression analysis was used to assess the risk factors for IDH. Results The incidence rate of IDH was 39.9%. In the 293 patients, 176 patients with <1/10 IDH events/3 months (defined as non-IDH) were served as controls, 80 patients were found to have ≥ 1/10 but ≤ 1/3 IDH events/3 months (occasional IDH), and 37 patients with > 1/3 IDH events/3 months (frequent IDH). We used ultrafiltration volum/body weight (UFV/W) to correlate with IDH, and the area under the ROC curve (AUC) of IDH was 0.706 (95% CI: 0.64～0.77, P<0.01). When the cut-off value of UFV/W was set at 4.33%, the sensitivity for IDH was 53.2% and the specificity for IDH was 76.5%. Multivariate regression analysis showed that age, ultrafiltration rate, serum NT-proBNP, serum albumin, and serum 2MG were associated with IDH among MHD patients. Conclusion Elderly, higher ultrafiltration rate, higher levels of serum NT-proBNP and 2MG, and hypoalbuminemia are independent risk factors for IDH among MHD patients.