Blood pressure, arterial waveform, and arterial stiffness during hemodialysis and their clinical implications in intradialytic hypotension
Blood pressure, arterial waveform, and arterial stiffness during hemodialysis and their clinical implications in intradialytic hypotension
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血液透析期间的血压、动脉波形和动脉僵硬度及其对透析中低血压的临床意义
DOI：
10.1038/s41440-022-01126-5
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发表时间：
2022
影响因子：
5.4
通讯作者：
Ishimitsu Toshihiko
中科院分区：
文献类型：
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作者：
Iwashima Yoshio;Fukushima Hiromichi;Horio Takeshi;Rai Tatemitsu;Ishimitsu Toshihiko
这项研究纳入了 152 名血液透析患者（平均年龄 69 岁；34.2% 为女性），使用示波设备 SphygmoCor XCEL 调查了血液透析期间血压 (BP) 和动脉僵硬度指数的系列变化，并检验了动脉波形评估是否对透析中低血压 (IDH) 的治疗具有临床意义。血液透析期间每 30 分钟进行一次测量，定义 IDH 的阈值是所有患者的收缩压 (SBP) 降低≥40mmHg 或需要抗低血压药物，并且在未使用抗低血压药物的亚组中≥血液透析期间最大 SBP 降低的第 75 个百分位 (≥34mmHg) (n=≥98)。在所有患者中，基线心内膜下存活率（SEVR）（心肌灌注指数）增加1个标准差（SD）是IDH的独立预测因子（比值比[OR] 0.43，p<0.001）。在亚组分析中，血液透析期间 IDH 的 SBP 和所有动脉波形指数（包括增强指数、增强压 (AP) 和 SEVR）的连续变化大于非 IDH 患者（通过 2 向重复测量方差分析，所有 p<0.01），但心率 (p= 0.40) 和舒张压时间指数 (p= 0.21) 除外。糖尿病 (OR 4.08)、超滤率 1-SD 增加 (OR 2.07)、缩短分数 (OR 0.45)、基线 SEVR (OR 0.36) 和 AP 的第一个 1 小时百分比变化 (OR 0.52) 是 IDH 的独立预测因素 (allp< 0.05)。总之，心肌灌注受损和动脉僵硬度增加，特别是小动脉对急性透析相关变化的反应性差，与 IDH 相关，透析前 SEVR 评估可以补充 IDH 筛查。
This study included 152 hemodialysis patients (mean age, 69 years; 34.2% female) and investigated serial changes in blood pressure (BP) and arterial stiffness indices during hemodialysis using an oscillometric device, SphygmoCor XCEL, and examined whether assessment of the arterial waveform has clinical implications for the management of intradialytic hypotension (IDH). Measurement was performed every 30 min during hemodialysis, and the threshold defining IDH was systolic BP (SBP) decrease ≥40 mmHg or a requirement for antihypotensive medication in all patients and ≥ the 75th percentile of maximum SBP decrease during hemodialysis (≥34 mmHg) in the subgroup without antihypotensive medication (n= 98). In all patients, a 1-standard deviation (SD) increase in the baseline subendocardial viability ratio (SEVR), an index of myocardial perfusion, was an independent predictor of IDH (odds ratio [OR] 0.43,p< 0.001). In the subgroup analysis, a serial change in SBP and all arterial waveform indices, including the augmentation index, augmented pressure (AP), and SEVR, during hemodialysis were greater for IDH than for non-IDH patients (allp< 0.01 by 2-way repeated-measures ANOVA), with the exception of heart rate (p= 0.40) and diastolic pressure time index (p= 0.21). Diabetes (OR 4.08), a 1-SD increase in ultrafiltration rate (OR 2.07), fractional shortening (OR 0.45), baseline SEVR (OR 0.36) and the first 1-h percent change in AP (OR 0.52) were independent predictors of IDH (allp< 0.05). In conclusion, impaired myocardial perfusion and increased arterial stiffness, particularly poor arteriolar responsiveness to acute dialysis-related changes, are associated with IDH, and predialysis SEVR evaluation can complement screening for IDH.