本文選題：血液透析 + 腹膜透析�。� 參考：《北京協(xié)和醫(yī)學(xué)院》2014年碩士論文

【摘要】：研究背景 血壓是影響透析患者預(yù)后的重要因素之一,既往的研究多集中于血壓絕對(duì)值本身,普通人群中越來越多研究發(fā)現(xiàn)血壓變異也是決定高血壓患者全因死亡及心腦血管死亡的獨(dú)立危險(xiǎn)因素。但是透析人群中血壓變異與預(yù)后的研究較少,目前還沒有關(guān)于腹透患者長時(shí)血壓變異與預(yù)后相關(guān)性的研究,關(guān)于血壓變異本身的影響因素研究更少。伴隨著透析過程的容量變化是維持性血透患者的重要特征之一,容量變化能夠影響短時(shí)血壓變異已有定論,但是尚無研究涉及其對(duì)長時(shí)血壓變異的影響。 研究目的 1、探討維持性血透患者及腹透患者血壓長時(shí)變異對(duì)預(yù)后的影響,分析容量變化對(duì)血壓長時(shí)變異的影響； 2、觀察維持性血壓患者短期容量變化與透析前后外周及中心動(dòng)脈血壓、血管彈性指標(biāo)關(guān)系,分析動(dòng)脈彈性及脈搏波折返的影響因素； 3、觀察維持性血透患者透析前后腎素、血管緊張素系統(tǒng)(RAS)變化,分析影響RAS活化的因素,探討水鈉變化與RAS變化的相關(guān)性。 研究方法 1.選擇北京協(xié)和醫(yī)院99例維持性血透患者及69例患腹膜透析患者作為研究對(duì)象。記錄99例血透患者2006年全年共計(jì)14703次透析的血壓、心率、透析前后體重變化,以血壓的變異系數(shù)(CV=SD/MEAN)作為血壓變異指標(biāo)。查閱69例患者2008年連續(xù)6次門診血壓記錄,同樣以血壓變異系數(shù)作為血壓變異指標(biāo)。收集患者一般臨床資料、生化指標(biāo),分別隨訪83個(gè)月及59個(gè)月,觀察患者預(yù)后資料,將死亡作為終點(diǎn)事件,用SPSS18.0統(tǒng)計(jì)軟件包進(jìn)行Cox回歸分析。 2.入選54例維持性血透患者,透析前后測(cè)量中心動(dòng)脈血壓(SphygmoCor, ArtCor), Omron-Colin測(cè)量肱—踝動(dòng)脈脈搏波傳播速度(baPWV),放免法測(cè)量透析前后血漿腎素活性(PRA)、血管緊張素Ⅱ (Angll)及醛固酮(ALD)水平,觀察容量變化與維持性血透患者血壓變化、RAS變化及血管彈性變化的相關(guān)性,使用SPSS18.0統(tǒng)計(jì)軟件包進(jìn)行單因素相關(guān)分析和多元回歸分析。 研究結(jié)果 1.兩組患者血壓與預(yù)后關(guān)系 隨訪期內(nèi)41例(41.4%)維持性血透患者死亡,31例(44.9%)腹透患者死亡心腦血管事件是兩組患者最主要的死亡原因,分別占61%及54.8%,血透患者以血管事件為主(80.0%),而腹透患者以心衰為主(52.9%)。透前SBP (preSBP)120mmHg是維持性血透患者全因死亡及心腦血管事件死亡的獨(dú)立危險(xiǎn)因素；門診SBP153mmHg是腹透患者全因死亡及心腦血管事件死亡的獨(dú)立危險(xiǎn)因素。 2.透前血壓變異及心率變異是血透患者死亡的獨(dú)立危險(xiǎn)因素 血透患者透前血壓變異是全因死亡的獨(dú)立危險(xiǎn)因素,透前血壓變異包括收縮壓變異系數(shù)(SBPCV)(HR1.200,95%CI1.046-1.378,P=0.010),舒張壓變異系數(shù)(DBPCV)(HR1.097,95%CI1.011-1.184, P=0.018)及收縮壓變化斜率(HR6.826,95%CI2.239-20.810, P=0.001)。透前收縮壓變異系數(shù)(DBPCV)(HR1.147,95%CI1.053-1.250, P=0.002)還是心腦血管事件死亡的獨(dú)立危險(xiǎn)因素。透前心率變異增加血透患者全因死亡風(fēng)險(xiǎn)(HR1.174,95%CI1.011-1.363,P=0.036)。腹透患者沒有觀察到類似現(xiàn)象。 多因素回歸分析發(fā)現(xiàn)收縮壓變異系數(shù)(SBPCV)與透析中體重減輕的變異成正相關(guān)(13=3.291,P=0.008)而與血白蛋白(ALB)成負(fù)相關(guān)(p=-0.218,P=0.010),舒張壓變異系數(shù)(DBPCV)與ALB (β=-0.413, P=0.031)成負(fù)相關(guān)。 3.血透患者透前血壓與容量呈正相關(guān),透后血管彈性發(fā)生變化 維持性血透患者透析間期體重增長(IDWG)與透前外周及中心動(dòng)脈SBP成正相關(guān)。伴隨著透析脫水,透析前后外周及中心血壓無差異,但是脈搏波折返減少,血管硬度增加,沒有觀察到這些變化與容量變化絕對(duì)值有關(guān)。 透析相關(guān)性高血壓與低血壓的發(fā)生與動(dòng)脈彈性及脈搏波折返有關(guān),按照透析第3小時(shí)與透前SBP差值是否大于10mmHg將54例患者分為透析相關(guān)性高血壓組及非高血壓組,透析相關(guān)性高血壓組透后壓力增強(qiáng)指數(shù)(Aix)高于非高血壓組(31.6±25.36%vs21.67±11.51%,P=0.000)。透析相關(guān)性高血壓組透后Aix升高,非高血壓組下降,兩組透后baPWV均升高但高血壓組升高幅度更明顯。按透析中最低SBP90mmHg或MAP下降30mmHg將患者分為透析中低血壓組(IDH)及非低血壓組,觀察到前者透后Aix更低(17.21±10.19%vs30.11±8.18%,P=0.000)。 4.部分血透患者透后RAS升高,升高幅度與水鈉清除量成正相關(guān) 透析過程中伴隨著水鈉的清除,出現(xiàn)PRA、AngⅡ、ALD升高的患者比例分別為47.4%,52.6%和30.6%。其增加幅度與透析中水鈉清除量成正相關(guān)。但近50%血透患者RAS對(duì)脫水無反應(yīng)。與非高血壓組相比,透析相關(guān)性高血壓組透后AngⅡ更低(92.53±39.09pg/ml vs67.85±13.28pg/ml, P=0.006)。 研究結(jié)論 1.透前血壓變異及心率變異增加維持性血透患者全因死亡及心腦血管死亡風(fēng)險(xiǎn)；透前血壓變異與容量變化及血白蛋白相關(guān)。沒有觀察到門診血壓變異與腹透患者死亡的相關(guān)性; 2.短期容量變化決定血透患者外周動(dòng)脈及中心動(dòng)脈血壓,部分血透患者存在伴隨水鈉清除的RAS活化； 3.透析中血管硬度及阻力變化是導(dǎo)致透析中血壓變化的主要原因,但RAS水平與血管硬度變化沒有相關(guān)性。
[Abstract]:Research background
Blood pressure is one of the important factors affecting the prognosis of dialysis patients. Previous studies are mostly focused on the absolute value of blood pressure itself. More and more studies in the general population have found that blood pressure variation is also an independent risk factor determining all causes of death and cardiovascular death in hypertensive patients. However, there are few studies on blood pressure variation and prognosis in dialysate population. There is no previous study on the correlation between long time blood pressure variability and prognosis in patients with peritoneal dialysis. There is less research on the influence factors of blood pressure variability itself. The effect of blood pressure variation.
research objective
1, to explore the effect of long term blood pressure variability on prognosis in patients with maintenance hemodialysis and peritoneal dialysis, and analyze the effect of volume changes on long term blood pressure variability.
2, the relationship between the changes of the short-term volume of the patients with maintenance blood pressure and the blood pressure of the central artery before and after the dialysis, the relationship between the vascular elasticity index, and the influencing factors of the arterial elasticity and pulse wave reentry were analyzed.
3, to observe the changes of renin and angiotensin system (RAS) before and after dialysis in patients with maintenance hemodialysis, to analyze the factors affecting the activation of RAS, and to explore the correlation between the changes of sodium water and the changes of RAS.
research method
1. in Peking Union Medical College Hospital, 99 patients with maintenance hemodialysis and 69 patients with peritoneal dialysis were selected as subjects. The blood pressure, heart rate, weight change before and after dialysis in 99 cases of hemodialysis were recorded in 99 cases of hemodialysis in 2006, and the variation coefficient of blood pressure (CV=SD/MEAN) was used as the index of blood pressure variation. 69 patients were consulted in 6 consecutive outpatients in 2008. The blood pressure variation was also used as the index of blood pressure variation. The general clinical data and biochemical indexes were collected for 83 months and 59 months respectively. The prognosis of the patients was observed, the death was taken as the end point, and the Cox regression analysis was carried out by the SPSS18.0 software package.
2. patients were enrolled in 54 patients with maintenance hemodialysis. The blood pressure of central artery (SphygmoCor, ArtCor) was measured before and after dialysis. The speed of brachial pulse pulse wave propagation (baPWV) was measured by Omron-Colin. Radioimmunoassay was used to measure the plasma renin activity (PRA), angiotensin II (Angll) and aldosterone (ALD) level before and after dialysis, and the changes of capacity and maintenance hemodialysis patients were observed. The correlation of blood pressure, RAS and vascular elasticity was analyzed by single factor correlation analysis and multiple regression analysis using SPSS18.0 statistical software package.
Research results
The relationship between blood pressure and prognosis in 1. two groups
During the follow-up period, 41 cases (41.4%) died of maintenance hemodialysis patients and 31 (44.9%) patients with peritoneal dialysis were the main causes of death in two groups, accounting for 61% and 54.8% respectively. Hemodialysis patients were mainly vascular events (80%), and the patients with peritoneal dialysis were mainly with heart failure (52.9%). SBP (preSBP) 120mmHg was the death of the patients with maintenance hemodialysis. SBP153mmHg is an independent risk factor for all-cause death and cardiovascular and cerebrovascular events in patients with peritoneal dialysis.
2. pre exposure blood pressure variability and heart rate variability are independent risk factors for mortality in hemodialysis patients.
Pre transmex blood pressure variation is an independent risk factor for all causes of death. Pre transmex blood pressure variation includes systolic pressure variation (SBPCV) (HR1.200,95%CI1.046-1.378, P=0.010), diastolic pressure variation (DBPCV) (HR1.097,95%CI1.011-1.184, P=0.018) and systolic pressure variation slope (HR6.826,95%CI2.239-20.810, P=0.001). Pre transdermal systolic pressure variation The coefficient (DBPCV) (HR1.147,95%CI1.053-1.250, P=0.002) is an independent risk factor for the death of cardio cerebral vascular events. Pre transmex heart rate variability increases the risk of all cause death in hemodialysis patients (HR1.174,95%CI1.011-1.363, P=0.036). No similar phenomenon has been observed in patients with peritoneal dialysis.
The multifactor regression analysis found that the systolic pressure variation coefficient (SBPCV) was positively correlated with the variation of weight loss in dialysis (13=3.291, P=0.008) and was negatively correlated with serum albumin (ALB) (p=-0.218, P=0.010), and the diastolic pressure variation coefficient (DBPCV) was negatively correlated with ALB (beta =-0.413, P= 0.031).
3. there was a positive correlation between blood pressure and volume before hemodialysis.
The interdialysis interval weight growth (IDWG) was positively related to the pre transdialysis and central artery SBP formation in the patients with maintenance hemodialysis. With dialysis dehydration, there was no difference in the peripheral and central blood pressure before and after dialysis, but the pulse wave reentry decreased and the blood vessel hardness increased, and no observation was made of the changes in the absolute value of the volume change.
The incidence of hypertension and hypotension in dialysis related hypertension was related to arterial elasticity and pulse wave reentry. 54 patients were divided into dialysis related hypertension group and non hypertensive group according to whether the difference between third hours and pre transdialysis SBP difference was greater than 10mmHg. The post dialysis pressure enhancement index (Aix) was higher than that of non hypertensive group (31.6 + 25.36%). Vs21.67 + 11.51%, P=0.000). After dialysis related hypertension, Aix increased and non hypertensive group decreased. The two groups increased baPWV after dialysis, but the increase in hypertension group was more obvious. According to the lowest SBP90mmHg or MAP drop in dialysis, the patients were divided into dialysate hypotension group (IDH) and non hypotension group, and the former was lower (17.21 + 10.) after dialysis (17.21 + 10.). 19%vs30.11 + 8.18%, P=0.000).
The 4. part is the increase of RAS in patients after hemodialysis, and the increase is positively correlated with the amount of water and sodium clearance.
With the removal of sodium water during dialysis, the proportion of patients with PRA, Ang II, and ALD increased, respectively, was 47.4%, 52.6% and 30.6%. were positively correlated with the sodium water removal in dialysis. But in nearly 50% hemodialysis patients, RAS did not respond to dehydration. Compared with the non hypertensive group, Ang II was lower in the dialysis related hypertension group (92.53 + 39.09pg/ml VS). 67.85 + 13.28pg/ml, P=0.006).
research conclusion
Blood pressure variation and heart rate variability increased the risk of death and cardiac and cerebrovascular death in patients with maintenance hemodialysis; pre transmence blood pressure variation was associated with volume change and serum albumin. No correlation between blood pressure variation and death of patients with peritoneal dialysis was observed.
2. the change of short-term capacity determines the blood pressure of peripheral artery and central artery in hemodialysis patients, and RAS activation in patients with partial hemodialysis is accompanied by sodium and sodium clearance.
3. changes in vascular stiffness and resistance during dialysis are the main causes of blood pressure changes during dialysis, but there is no correlation between RAS level and vascular stiffness changes.
【學(xué)位授予單位】：北京協(xié)和醫(yī)學(xué)院
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2014
【分類號(hào)】：R692.5

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本文編號(hào)：1961033