尿毒症合并急性失代偿性心力衰竭伴低血压患者序贯单纯超滤和血液透析治疗的有效性和安全性的初步探索研究

Preliminary study on the effectiveness and safety of sequential simple ultrafiltration and hemodialysis in patients with uremia complicated with acute decompensated heart failure and hypotension

目的初步探讨序贯单纯超滤和血液透析治疗对于尿毒症合并急性失代偿性心力衰竭(ADHF)伴低血压患者的有效性和安全性。方法入选2018年8月至2021年12月于扬州友好医院住院因尿毒症合并ADHF伴低血压行序贯单纯超滤和血液透析治疗的患者。有效性评价包括续贯治疗前后纽约心脏协会(NYHA)心功能分级及呼吸困难评分改善情况,以及一些指标如体质量、呼吸频率、心率、心输出量、左心室射血分数(LVEF)、N末端B型利钠肽原(NT-proBNP)及血肌酐水平在治疗前后的变化。安全性评价包括血压、血钾、血钠及血红蛋白等指标在治疗前后的变化,以及续贯治疗期间安全性终点事件的发生情况。结果研究共入选了25例患者,年龄为(71.9±4.5)岁,男性18例(72.0%),续贯治疗前的NYHA心功能Ⅱ级、Ⅲ级和Ⅳ级分别为3例(12.0%)、18例(72.0%)和4例(16.0%),收缩压为(82.2±6.4)mmHg(1 mmHg=0.133 kPa),心率为(110.1±9.7)次/分。续贯治疗后患者的NYHA心功能分级及呼吸困难评分均较治疗前明显改善,总有效率均为100%。与续贯治疗前比较,续贯治疗后患者体质量下降[(72.98±6.29)kg比(64.99±8.32)kg],呼吸频率降低[(32.2±4.7)次/min比(20.2±4.4)次/min],心率降低[(110.1±9.7)次/min比(84.11±10.13)次/min],心输出量提高[(3.03±1.24)L/min比(5.09±1.14)L/min],LVEF水平提高[(28.92±7.35)%比(43.91±8.31)%],NT-proBNP水平下降[(6988.34±488.85)pg/mL比(2986.32±598.93)pg/mL],血肌酐水平下降[(717.22±13.7)μmol/L比(289.38±13.9)μmol/L],差异均有统计学意义(P均<0.01)。治疗前后患者的收缩压、舒张压、血钾、血钠及血红蛋白水平无显著变化(P均>0.05)。所有患者在续贯治疗期间期间未发生严重心律失常或出血、血栓栓塞、猝死等不良事件。结论对尿毒症合并ADHF伴低血压患者施行序贯单纯超滤和血液透析治疗有效且安全,值得进一步开展更大规模研究。

Objective To preliminarily investigate the effectiveness and safety of sequential simple ultrafiltration and hemodialysis in the treatment of patients with uremia complicating acute decompensated heart failure(ADHF)and hypotension.Method Patients hospitalized with uremia complicating ADHF and hypotension undergoing sequential simple ultrafiltration and hemodialysis from August 2018 to December 2021 in the Yangzhou Friendship Hospitial were enrolled.The effectiveness was evaluated by the improvement of the New York Heart Association(NYHA)functional class and dyspnea score,as well as changes of some parameters after sequential treatment,such as body weight,respiratory rate,heart rate,cardiac output,left ventricular ejection fraction(LVEF),N terminal-pro B type natriuretic peptide(NT-proBNP)and serum creatinine levels.Meanwhile,the safety was assessed by the changes of blood pressure,serum potassium and sodium,and hemoglobin before and after sequential treatment as well as the occurrence of safety outcome events.Result A total of 25 patients were enrolled with the age of(71.9±4.5)years and 18 males(72.0%).Before treatment,patients with NYHA functional classⅡ、ⅢandⅣwas 3(12.0%)、18(72.0%)and 4(16.0%),respectively,and the systolic blood pressure and heart rate before treatment was(82.2±6.4)mmHg(1 mmHg=0.133 kPa)and(110.1±9.7)beats per minute(bpms).All the patients showed significant improvement in the NYHA functional class and dyspnea score.Compared with those before treatment,patients showed significant decrease in body weight[(72.98±6.29)kg vs.(64.99±8.32)kg],respiratory rate[(32.2±4.7)breaths per minute vs.(20.2±4.4)breaths per minute],heart rate[(110.1±9.7)bpms vs.(84.11±10.13)bpms],NT-proBNP[(6988.34±488.85)pg/mL vs.(2986.32±598.93)pg/mL]and serum creatinine[(717.22±13.7)μmol/L vs.(289.38±13.9)μmol/L]as well as increase in cardiac output[(3.03±1.24)L/min vs.(5.09±1.14)L/min]and LVEF[(28.92±7.35)%vs.(43.91±8.31)%](all P<0.01)after sequential treatment.Meanwhile,there was no significant differences in blood pressure,serum potassium and sodium,and hemoglobin before and after treatment.No adverse event including serious arrhythmia,hemorrhage,thromboembolism and sudden death,occurred during the sequential treatment.Conclusion Sequential simple ultrafiltration and hemodialysis are effective and safe in patients with uremia complicating ADHF and hypotension and further studies are warranted.