中国血液净化

中国血液净化 ›› 2016, Vol. 15 ›› Issue (10): 545-549.doi: 10.3969/j.issn.1671-4091.2016.10.008

• 临床研究 • 上一篇    下一篇

RAAS对MHD患者透析过程中血压波动的影响及相关因素分析

张颖莹,张昆,王爱丽,李江涛,刘熹,余晨   

  1. 同济大学附属同济医院肾内科
  • 收稿日期:2016-03-25 修回日期:2016-08-04 出版日期:2016-10-12 发布日期:2016-10-10
  • 通讯作者: 余晨 yuchen@hotmail.com E-mail:yuchen@tongji.edu.cn
  • 基金资助:

    国家自然基金面上项目（81370790），国家自然基金青年项目（81400697）

Correlation between the renin-angiotensin-aldosterone system and variation of intradialytic blood pressure in patients during maintenance hemodialysis and the analysis of related factors

  • Received:2016-03-25 Revised:2016-08-04 Online:2016-10-12 Published:2016-10-10

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摘要： 目的研究维持性血液透析患者肾素-血管紧张素-醛固酮系统(Renin-angiotensin- aldosterone system，RAAS)水平与透析过程中血压波动的关系及相关影响因素的分析。方法选择上海市同济医院维持性血液透析的患者，根据透析过程中血压变化分为透析低血压组，透析高血压组及透析血压稳定组，比较各组患者生化、RAAS 及内皮系统相关指标的变化及其相关性分析。结果透析高血压组较血压稳定组的血管紧张素转化酶(angiotensin-converting enzyme, ACE)(37.022±9.482)U/L 比(25.415 ± 10.215)U/L(t=- 3.618,P=0.023)、血管紧张素II(angiotensin II，AngII) (97.269 ±47.256)ng/L 比(75.334±27.205)ng/L(t=- 1.727，P=0.018)及醛固酮(aldosterone，ALD) (176.469± 67.070)ng/L 比(124.093±42.642)ng/L(t=-2.901，P=0.007)均明显升高，透析低血压组的ACE、AngII 及ALD 较透析血压稳定组有升高趋势，但ALD 水平较透析血压稳定组明显降低(163.034±53.266)ng/L 比(124.093±42.642)ng/L(t=2.286，P=0.030)。血清一氧化氮(Nitric oxide，NO)水平变化趋势透析血压稳定组高于透析低血压组高于透析高血压组(74.371±27.650)μmol/L 比(65.566±16.785)μmol/L比(60.430±17.906)μmol/L(F=2.024，P=0.143)。然而血清血管内皮素-1(endothelin-1,ET-1)水平与血清NO 水平趋势相反[(3.650±1.291)pg/ml 比(4.313±1.414)pg/ml 比(4.819±1.938)pg/ml,(F=2.539，P=0.089)，其中血压稳定组较透析高血压组降低明显(t=-2.208，P=0.034)。NO/ET-1 比值透析低血压组及透析高血压组均低于透析血压稳定组[(15.756±3.257)及(14.035± 4.845)比(20.614±7.485)]，且存在统计学差异(t=-2.486，P=0.026;t=3.178，P=0.003)。通过多元逐步线性回归分析显示除RAAS 及内皮功能外透析间期体质量增长(interdialysis weight gain，IDWG)(B=1.482，P=0.001)、心血管合并症(B=4.578，P=0.001)、糖尿病(B=3.038，P=0.024)、性别(B=-2.183，P=0.035)、透龄(B=-0.167，P=0.018)与透析血压变化相关。结论①RAAS 激活及内皮功能紊乱与透析患者透析过程血压波动密切相关。②透析间期容量负荷增加为导致透析高血压的原因之一。③IDWG、透龄、心血管并发症、糖尿病为影响透析过程血压波动的独立危险因素。

关键词: 血液透析, 血压波动, RAAS

Abstract: Objective The aim of this study was to investigate the relationship between serum renin-angiotensin-aldosterone system (RAAS) level and the variation of intradialytic blood pressure in maintenance hemodialysis patients during dialysis sessions. Methods Fifty-three MHD patients were enrolled in this trial.
Fifteen of them had intradialytic hypotension, 20 of them had intradialytic hypertension, and the rest of the patients had intradialytic stable BP. Plasma levels of angiotensin- II (Ang-II), aldosterone (ALD), angiotensinconverting enzyme (ACE), endothelin-1 (ET-1), and nitric oxide (NO) were measured. Results Serum Ang-II, ACE, and ALD were significantly higher in intradialytic hypertension group than in intradialytic stable BP group (97.269±47.256 ng/L vs. (75.334±27.205)ng/L, t=-1.727, P=0.018 for Ang-II; (37.022±9.482)U/L vs. (25.415 ± 10.215)U/L, t=- 3.618, P=0.023 for ACE; [(176.469 ± 67.070)ng/L vs. (124.093 ± 42.642)ng/L, t=-2.901, P=0.007 for ALD]. Serum levels of Ang-II, ACE and ALD were higher in intradialytic hypotension group than in intradialytic stable BP group, but only ALD level was statistically significant [(163.034±53.266) ng/L vs. (124.093 ± 42.642)ng/L, t=2.286, P=0.030]. Serum NO was the highest in intradialytic stable BP group (74.371±27.650) μmol/L, followed by intradialytic hypotension group (65.566±16.785) μmol/L and intradialytic hypertension group [(60.430 ± 17.906) μmol/L; F=2.024, P=0.143]. In contrast, serum ET-1 was the lowest in intradialytic stable BP group (3.650 ± 1.291 pg/ml), followed by intradialytic hypotension group (4.313±1.414 pg/ml) and intradialytic hypertension group [(4.819±1.938) pg/ml; F=2.539, P=0.089]; serum ET- 1 was significantly lower in intradialytic stable BP group than in intradialytic hypertension group (t=-2.208, P=0.034). NO/ET-1 ratio was significantly lower in intradialytic hypotension group and intradialytic hypertension group than in intradialytic stable BP group (15.756±3.257 vs. 20.614±7.485, t=-2.486, P=0.026 between intradialytic hypotension group and intradialytic stable BP group; 14.035±4.845 vs. 20.614±7.485, t= 3.178, P=0.003 between intradialytic hypertension group and intradialytic stable BP group). Multiple stepwise regression analysis found that interdialysis weight gain (IDWG; B=1.482, P=0.001), cardiac complications (B= 4.578, P=0.001), diabetes mellitus (B=3.038, P=0.024), gender (B=- 2.183, P=0.035), and dialysis vintage (B= -0.167, P=0.018) correlated with intradialytic BP changes, but serum RAAS parameters and NO/ET-1 ratio did not correlated with intradialytic BP changes. Conclusion Activation of RAAS and endothelial dysfunction relate to the variation of intradialytic blood pressure in MHD patients during dialysis sessions. Fluid overload may play a role in the pathogenesis of intradialytic hypertension. IDWG, diabetes mellitus, gender, cardiac complications and dialysis vintage affect the level of blood pressure during dialysis sessions.

Key words: Hemodialysis, Variation of Intradialytic Blood Pressure, Renin- angiotensin- aldosteronesystem