血液透析患者透析中低血压的发生情况及其与预后的关系

The prevalence of intradialytic hypotension under different diagnostic criteria and its association with mortality

目的探讨维持性血液透析（MHD）患者透析中低血压（IDH）的发生率及其与患者死亡的关系，探寻适宜中国MHD患者IDH的诊断标准。方法纳入2012年7月1日至2012年7月31日期间于上海交通大学医学院附属瑞金医院血液透析中心接受血液透析治疗的尿毒症患者为研究对象。收集患者一般临床资料、入组前6个月的透析前血压、透析中最低血压，及透析后血压、生化检查和心脏超声检查结果等资料，对人组患者进行为期3年的随访（至2015年7月）。统计不同IDH诊断标准下NHD患者IDH的发生率和患病率，分析IDH发生与患者死亡的相关关系。基于文献报道中单纯以血压为标准的11种IDH诊断标准，以是否发生IDH将患者分为无IDH组和IDH组。结果219例患者纳入本研究，共行血液透析16084例次。在不同IDH诊断标准下，MHD患者IDH患病率、总体及个体IDH发生率分别波动于45．21％～100．00％，4．64％-37．60％及0．00％-33．00％。生存分析结果显示，以透析中最低动脉收缩压〈90mmHg标准单独诊断，或同时符合透析中动脉收缩压下降≥20mmHg诊断标准的IDH是患者心血管疾病死亡的保护因素（P〈0．05），与患者全因死亡率无相关。与无IDH组相比，IDH组患者的心功能较好；血B型脑钠肽前体（Pro．BNP）较低（6909ng／L比2880ng／L）；左室肥厚患病率较低（83．0％比52．0％）；左室射血分数较高（62．5％比65．0％）（均P〈0．05）。其余各标准下IDH发生与患者全因死亡风险和心血管疾病死亡风险无相关性。结论不同诊断标准下MHD患者的IDH患病率、IDH总体发生率与个体发生率有明显差异，发生IDH与患者的全因死亡率无明显相关。透析中最低动脉收缩压〈90mmHg或同时伴透析中动脉收缩压下降≥20mmHg的IDH患者，由于心功能相对较好，心血管疾病死亡风险相对较小。

Objective Intradialytic hypotension （IDH） is one of the common complications during hemodialysis, however its diagnostic criteria are highly controversial at present. In order to fully understand the prevalence of IDH in our center and figure out which diagnostic criteria is better for Chinese maintenance hemodialysis （MHD） patients, we choose several IDH definitions by reviewing published literatures and analyze their association with mortality. Methods The patients were recruited from Blood Purification Center of Ruijin Hospital undergoing hemodialysis during July 2012. Pre-, intra- and post-dialysis blood pressure were recorded. Patients＇ clinical characteristics, laboratory results and cardiac ultrasound results were collected. Based on several IDH definitions, we investigated the prevalence rate of IDH and its frequency among MHD patients. SPSS 23.0 was used to analyze data and conduct survival analysis. Results Totally 219 MHD patients underwent 16084 hemodialysis in 6 months. The prevalence rate, overall and individual frequency of IDH fluctuated between 45.21%- 100.00%, 4.64%-37.60% and 0.00%- 33.00% respectively. For every IDH criteria, the patients were recruited into the group IDH（＋） if they ever met the corresponding definition, otherwise the group IDH（-）. Survival analysis found that IDH （the criteria of an absolute systolic blood pressure （SBP） 〈 90 mmHg or with a decrease of SBP~〉 20 mmHg） could decrease the risk of patients＂ cardiovascular mortality but was not relevant to all-cause mortality. Further analysis showed these patients had better cardiac functions mainly reflecting in lower Pro-BNP （2880 ng/L vs 6909 ng/L）, lower prevalence rate of left ventricular hypertrophy （52% vs 83%） and higher left ventricular ejection fraction （65.0% vs 62.5% ） than IDH（-） patients. No correlation was found between other IDH criteria and mortality. Conclusions The prevalence rate, overall and individual IDH frequency of IDH are of high variability when diagnosed by different IDH criteria. All IDH episodes defined by our selected definitions are of no association with all-cause mortality. An absolute SBP 〈 90 mmHg or with a decrease of SBP≥20 mmHg can decrease the risk of cardiovascular mortality due to their better cardiac function. Large scale researches should be conducted to find optimal IDH definition and explore the association of IDH and mortality.