血液透析患者血压变异性与全因及心脑血管疾病死亡的关系

Relationship between Blood Pressure Variability and All-cause and Cardiac-cerebral Vascular Disease Mortality in Hemodialysis Patients

目的探讨维持性血液透析(maintenance hemodialysis,MHD)患者血压变异性(blood pressure variability,BPV)与全因和心脑血管疾病(cardiac-cerebral vascular disease,CCVD)死亡的关系。方法选取MHD患者102例,记录临床资料、化验指标及连续10次透析前的血压数值,根据透析前收缩压变异系数(SBP-CV)中位数(7.4%)将患者分为低SBP-CV组(3.3%~7.3%)和高SBP-CV组(7.5%~15.6%)。所有患者随访48个月,记录随访期间MHD患者死亡时间及死因。结果与低SBP-CV组比较,高SBP-CV组中糖尿病患病比例更高,透析超滤量更大,而血肌酐和血浆白蛋白水平更低(P<0.05)。而两组患者年龄、性别构成比、透析龄、透前收缩压、透前舒张压、血红蛋白、Kt/V以及服用降压药物种类比较,差异均无统计学意义(P>0.05)。在48个月的随访期内,102例MHD患者中死亡39例,其中CCVD死亡19例。低SBP-CV组和高SBP-CV组全因病死率分别为33.3%和43.1%,两组比较差异无统计学意义(P>0.05),而两组CCVD病死率分别为9.8%和27.5%,两组比较差异有统计学意义(P<0.05)。对全因死亡生存曲线进行比较,两组生存率差异无统计学意义(P>0.05)。而对CCVD死亡生存曲线比较,高SBP-CV组生存率显著低于低SBP-CV组,差异有统计学意义(P<0.05)。Cox回归分析显示,高血磷(HR=3.287,90%CI:1.469~7.357)和高C反应蛋白水平(HR=1.026,95%CI:1.007~1.045)是MHD患者全因死亡的独立预测因子(P<0.01),同时高血磷(HR=4.175,95%CI:1.317~13.235)也是CCVD死亡的独立预测因子(P<0.05)。而高血肌酐水平是MHD患者全因(HR=0.996,95%CI:0.994~0.998)及CCVD(HR=0.995,95%CI:0.992~0.997)死亡的保护因子(P<0.01)。结论高水平透析前SBP-CV可能与增加的CCVD死亡相关,但其并不是CCVD死亡的独立预测因子,而高血磷是全因死亡和CCVD死亡的独立预测因子,血肌酐是保护因子。

Objective To investigate the relationship between blood pressure variability （BPV） and all- cause and cardiac -cere- bral vascular disease （CCVD） mortality in maintenance hemodialysis （MHD） patients. Methods Totally 102 stable MHD patients were recruited in Dialysis Center of Beijing Tongren Hospital. The general data and pre -dialytic systolic blood pressure （SBP） and diastolic blood pressure （DBP） were recorded. The pre- dialytic SBP coefficient of variation （CV） was used as an indicator of BPV. MHD pa- tients were divided into the low SBP -CV group （3.3% -7.3% ） and the high SBP- CV group （7.5% -15.6% ） according to the me- dian of SBP- CV （7.4%）. All patients were followed up for 48 months. The time and cause of death were recorded during this period. Results In the high SBP - CV group, the rate of diabetes and ultrafihration volume were significantly increased （P 〈 0. O1 ）, and the pre - dialytic levels of serum creatinine and plasma albumin were significantly deceased compared with the low SBP - CV group （ P 〈 0. 05）. There were no significant differences in age, ratio of sex, dialytic age, pre- dialytic SBP, pre- dialytic DBP, hemoglobin, Kt/ V and the types of taking antihypertensive drugs between the two groups （P 〉 O. 05）. During the follow -up period, 39 died in the 102 MHD patients. Among them 19 died of CCVD and accounted for 48.7% of the total mortality. All - cause mortality in the low SBP - CV group and the high SBP - CV group was 33.3% and 43.1% （P 〉 0.05 ）. CCVD mortality was 9.8% and 27.5% （ P 〈 0.05 ）. There was no significant difference in survival curves of all - cause mortality between the two groups （ P 〉 0.05 ）. The survival curves for CCVD mortality was significantly lower in the high SBP - CV group than in the low SBP - CV group （ P 〈 0.05 ）. By Cox regression analysis,high blood phosphate （ HR = 3. 287,95 % CI ： 1. 469 - 7. 357 ） and C - reactive protein （ HR = 1. 026, 95 % CI ： 1. 007 - 1. 045 ） levels were independent predictors of all - cause mortality in MHD patients （ P 〈 0.01 ） , meanwhile high blood phosphate levels （ HR = 4. 175, 95% CI ： 1. 317 - 13. 235 ） were also an independent predictor of CCVD mortality （P 〈 0.05 ）. However, high serum creatinine levels were aprotective factor of all-cause （HR=0.996, 0.994-0.998） and CCVD （HR=0.995, 95%CI：0.992-0.997） mortality （P〈 0.01 ）. Conclusion Greater pre - dialytic SBP variability may be predictive factor of CCVD mortality. High blood phosphate levels and high serum creatinine should be a protective factor. associated with increased CCVD mortality, but it is not an independent should be an independent predictor of all - cause and CCVD mortality.