Redefining the Burden of Intradialytic Hypotension in the Modern Era of Hemodialysis.
Redefining the Burden of Intradialytic Hypotension in the Modern Era of Hemodialysis.
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重新定义现代血液透析时代透析中低血压的负担。
DOI：
10.1159/000500878
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发表时间：
2019
影响因子：
4.2
通讯作者：
VanBuren,PeterNoel
中科院分区：
文献类型：
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作者：
VanBuren,PeterNoel
血液透析患者的血压（BP）管理仍然具有挑战性，部分原因是透析治疗期间和透析治疗之间的BP变化。尽管大多数患者透析前后血压适度降低，但其他患者的血压升高或大幅降低，目前已知与死亡率增加相关。避免透析期间低血压的直接目标是确保患者安全并限制不愉快的症状。长期目标是避免重要器官的复发性灌注不足，并避免可能导致慢性细胞外容量超负荷（一种独立的死亡风险因素）的超滤中断。透析中低血压（IDH）的传统定义已在临床实践指南中进行了说明（收缩压降低> 20 mm Hg并伴有相应症状），但最近的一项研究证实了至少30%的暴露治疗中最低收缩压< 90 mm Hg的定义相关的死亡风险[1]。在本期《美国肾脏病学杂志》中，Kuipers等人。[2]承认血液透析患者的人口统计学随着时间的推移发生了变化，用于最大限度地减少IDH的干预措施也发生了变化。他们的目的是量化IDH的传统和新定义的最新流行率。在这项荟萃分析中，作者回顾了过去28年的研究（最终分析包括> 3项研究中的23项，000筛选），使用各种定义解决IDH患病率，但主要集中在收缩压降低> 20 mm Hg，伴有临床症状或干预，或收缩压最低值<20 mm Hg。90毫米汞柱。使用前一种定义，他们发现IDH的患病率范围为5 - 31%，平均患病率为9.7%。当使用收缩压最低值< 90 mm Hg时，患病率范围为4 - 17%，最终分析中平均患病率为4.7%。他们发现，经历IDH的患者比例范围为6 - 77%和10 - 75%，但由于IDH的合格频率差异（1次治疗至30%的治疗），他们没有对这些结果进行荟萃分析。毫不奇怪，在个体研究中，糖尿病和透析间期体重大幅增加经常被报告为IDH的危险因素。进一步的结论是，IDH的绝对降低和症状定义一致报告为10%，而不是在单次治疗中包括多次发作的研究中，但收缩压最低值< 90 mm Hg在不同研究中更不均匀。作者承认其分析的局限性在于观察期或如何确定透析中症状的标准化方法的差异。
Blood pressure (BP) management in hemodialysis patients remains challenging, in part due to the BP changes during and between dialysis treatments. Although a modest reduction in BP from pre to postdialysis occurs in most patients, other patients experience either increases or large decreases in BP that are now known to be associated with increased mortality. The immediate goal of avoiding hypotension during dialysis is to ensure patient safety and limit unpleasant symptoms. Long-term goals are to avoid recurrent hypoperfusion of vital organs and avoid interruptions in ultrafiltration that can result in chronic extracellular volume overload, an independent mortality risk factor. Traditional definitions of intradialytic hypotension (IDH) have been stated in clinical practice guidelines (reduction in systolic BP> 20 mm Hg with corresponding symptoms), but a more recent study validated the mortality risk associated with the definition of nadir systolic BP< 90 mm Hg in at least 30% of exposure treatments [1]. In this issue of American Journal of Nephrology, Kuipers et al.[2] acknowledge that the demographic of hemodialysis patients has changed over time as have the interventions used to minimize IDH. They aimed to quantify the updated prevalence of the traditional and novel definitions of IDH.In this meta-analysis, the authors reviewed studies from the past 28 years (final analysis included 23 studies out of> 3,000 screened) that addressed IDH prevalence using a variety of definitions but focusing mostly on a decrease in systolic BP> 20 mm Hg with clinical symptoms or intervention or a nadir systolic BP< 90 mm Hg. Using the former definition, they found the prevalence of IDH to range from 5 to 31% with a mean prevalence of 9.7%. The prevalence ranged from 4 to 17% when the systolic BP nadir< 90 mm Hg was used with a mean prevalence of 4.7% in the final analysis. They found the proportion of patients that experienced IDH to range from 6 to 77 and 10 to 75% for the respective definitions, but they did not conduct a meta-analysis of these outcomes due to differences in the qualifying frequency of IDH (1 treatment to 30% of treatments). Not surprisingly, the presence of diabetes and large interdialytic weight gain were frequently reported in the individual studies as risk factors for IDH. Further conclusions were that the absolute decrease and symptoms definition of IDH was consistently reported as 10% other than in studies where multiple episodes in a single treatment were included, but the systolic nadir< 90 mm Hg was more heterogeneous across different studies. The authors acknowledged that limitations of their analysis were the differences in observation period or standardized approach to how intradialytic symptoms were ascertained.