左甲状腺素钠片治疗合并有甲状腺激素水平下降的透析性低血压患者的临床疗效观察

Clinical observation of oral sodium levothyroxine in the treatment of intradialytic hypotension complicated with low serum thyroid hormone in maintenance hemodialysis patients

目的 研究左甲状腺素钠片治疗合并有甲状腺激素水平下降的维持性血液透析患者透析性低血压（intradialytic hypotension,IDH）的临床疗效及可能的机制.方法 选取黄石二医院2012年6月～2013年6月血液透析中心有IDH发作史且合并有甲状腺激素（thyroid hormones,TH）水平下降的患者共40例作为研究对象.首先研究TH水平与IDH发作频数的关系.再随机分成2组,分别将2组中愿意接受左甲状腺素钠片（Levothyroxine Sodium,LT4）治疗的归为治疗组（n=19）,不愿接受LT4治疗的归为对照组（n=18）.再研究2组在治疗前后的IDH发作频数和各观察指标的变化.服药方法：LT4 （25ugqd）服用1周后若无不良反应改为50ug qd完成24周疗程.服药过程中出现不适的将药物减量原用量的1/2～1/4,有明显副反应的停药. 结果 40例有低TH水平的占IDH总例数的72.7％.40例患者游离甲状腺素（free thyroxine,FT4）水平与IDH发作频数有负相关性（R=-0.443,P=0.004）.治疗组中1例因出现胸闷心悸中途退出,2例因IDH缓解后自行停药.与对照组相比治疗组服药后的IDH发作频数较前减少（0.10±0.052比0.20±0.127,P=0.003）,游离三碘甲状腺原氨酸（free triiodothyronine,FT3）（4.63±0.765比3.84±0.697 pmol/1,P=0.003）和白蛋白（ALB） （40.86±3.148g/L比39.06±1.990g/L,P=0.045）增加均具有统计学意义.与治疗前相比治疗组以下指标：FT4 （7.33±1.190pmol/L比8.54±1.399 pmol/L,P=0.009）,FT3（3.59±0.603比4.63±0.765pmol/L,P＜0.001）,血红蛋白（HGB）（69.89±21.891比82.61±11.49 g/L,P=0.007）,白蛋白（ALB）（38.01±3.050g/L比40.86±3.148 g/L,P=0.009）,血清铁（7.26±3.27 mmol/L比9.39±1.56 mmol/L,P=0.006）,左心室射血分数（LVEF）（49.32％±6.67％比51.63％±6.87％,P=0.014）均较前增高.IDH发作频数较前减少（0.10±0.052比0.22±0.118,P＜0.001）结论 LT4纠正合并TH水平下降的IDH患者的低TH水平可有效减少的IDH发作频数.这可能与提高了患者的心脏左室射血分数以及改善了患者的贫血以及低白蛋白血症有关.

Objective To investigate the clinical efficacy and mechanism of oral sodium levothyroxine （LT4） in the treatment of intradialytic hypotesion （IDH） complicated with low thyroid hormone （TH） in maintenance hemodialysis （MHD） patients.Methods We recruited 40 MHD patients with IDH and low serum TH for at least 3 months during the period from June 2012 to June 2013.The relationship between serum TH level and IDH frequency in MHD patients was evaluated.The patients were then divided into two groups,LT4 treatment group （n=19） and control group （without LT4 treatment,n=18）.Changes of IDH frequency and clinical parameters after the therapy for 24 weeks were observed in the two groups.LT4 was administrated orally 25μg/day for one week at the beginning,and then increased to 50μg/day for 24 weeks if no side-effects were found.LT4 should be reduced to 1/2～ 1/4 of the original dosage when side-effects were present,and should be terminated when serious adverse reactions occurred.Results Low serum TH level was found in 72.7％ MHD patients with IDH.In the 40 MHD patients with IDH and low TH,free thyroxine （FT4） was negatively correlated with IDH frequency （R=-0.443,P=0.004）.LT4 therapy terminated in 3 patients because of chest distress and palpitation in one case and no IDH anymore in 2 cases.In LT4 treatment group,IDH frequency reduced （0.10±0.052 vs.0.20±0.127,P=0.003） with the increases of free triiodothyronine （FT3） （4.63±0.765 vs.3.84±0.697 pmol/1,P=0.003） and serum albumin （40.86±3.148 vs.39.06± 1.990 g/L,P=0.045）,as compared with those in control group.Compared with the parameters before LT4 treatment,MHD patients after LT4 therapy showed the changes of FT4 （7.33± 1.190pmol/L,to 8.54± 1.399 pmol/L,P=0.009）,FT3 （3.59± 0.603pmol/L to 4.63±0.765 pmol/L,P＜0.001）,hemoglobin （69.89±21.891g/L to 82.61± 11.49 g/L P=0.007）,albumin （38.01±3.050g/L to 40.86±3.148 g/L,P=0.009）,serum iron （7.26±3.27mmol/L to 9.39±1.56 mmol/L,P=0.006）,left ventricular ejection fraction （49.32％±6.67％ to 51.63％±6.87％,P=0.014）,and IDH frequency （0.22±0.118 to 0.10±0.052,P＜0.001）.Conclusion Oral LT4 therapy can reduce IDH frequency in MHD patients with low serum TH level.The effects of LT4 may relate to the increase of LVEF and improvement of anemia and nutrition status in these patients.