Pathophysiology of dialysis hypotension: An update
Pathophysiology of dialysis hypotension: An update
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DOI：
10.1053/ajkd.2001.28090
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发表时间：
2001-10-01
影响因子：
13.2
通讯作者：
Daugirdas, JT
中科院分区：
文献类型：
--
作者：
Daugirdas, JT
透析性低血压的发生是因为大量的血液水和溶质在短时间内被去除，压倒了正常的代偿机制，包括血浆再充盈和静脉容量减少，这是由于向静脉的压力传递减少。在一些患者中，可能发生看似矛盾和不适当的交感神经张力降低，导致小动脉阻力降低，向静脉的压力传递增加，静脉容量相应增加。在血容量不足的情况下，静脉中的血液隔离增加会降低心脏充盈、心输出量，并最终降低血压。由于组织缺血导致的腺苷释放可能参与局部去甲肾上腺素释放的减少，并且在某些但尚未明确的心脏病理学患者中，Bezold-Jorsch反射的激活可能是突发透析低血压的原因。舒张功能不全的患者可能对心脏充盈减少的影响更敏感。最终的解决方案是通过使用更长的透析时间、更频繁的透析或减少盐的摄入来降低超滤率。增加透析液氯化钠水平有助于维持血容量和再充盈，但最终会增加口渴和透析间期体重增加，可能对高血压产生不良影响。超滤或透析液钠反馈回路的血容量监测是有前途的新策略。通过足够的血红蛋白水平维持组织氧合似乎很重要。腺苷拮抗剂的使用仍处于试验阶段。鉴于交感神经戒断的重要性，使用药理学交感神经激动剂在理论上是一种有吸引力的治疗策略。(C)2001年由国家肾脏基金会，公司。
Dialysis hypotension occurs because a large volume of blood water and solutes are removed over a short period of time, overwhelming normal compensatory mechanisms, including plasma refilling and reduction of venous capacity, due to reduction of pressure transmission to veins. In some patients, seemingly paradoxical and inappropriate reduction of sympathetic tone may occur, causing reduction of arteriolar resistance, increased transmission of pressure to veins, and corresponding increase in venous capacity. Increased sequestration of blood in veins under conditions of hypovolemia reduces cardiac filling, cardiac output, and, ultimately, blood pressure. Adenosine release due to tissue ischemia may participate in reducing norepinephrine release locally, and activation of the Bezold-Jarisch reflex, perhaps in patients with certain but as yet undefined cardiac pathology, may be responsible for sudden dialysis hypotension. Patients with diastolic dysfunction may be more sensitive to the effects of reduced cardiac filling. The ultimate solution is reducing the ultrafiltration rate by use of longer dialysis sessions, more frequent dialysis, or reduction in salt intake. Increasing dialysis solution sodium chloride levels helps maintain blood volume and refilling but ultimately increases thirst and interdialytic weight gain, with a possible adverse effect on hypertension. Blood volume monitoring with ultrafiltration or dialysis solution sodium feedback loops are promising new strategies. Maintaining tissue oxygenation via an adequate blood hemoglobin level seems to be important. Use of adenosine antagonists remains experimental. Given the importance of sympathetic withdrawal, the use of pharmacologic sympathetic agonists is theoretically an attractive therapeutic strategy. (C) 2001 by the National Kidney Foundation, Inc.