Cannella G, Paoletti E, Ravera G, Cassottana P, Araghi P, Mulas D, Peloso G, Delfino R, Messa P
Divisione di Nefrologia e Dialisi, Dipartimento di Scienze della Salute, Sezione di Biostatistica dell'Università and I Divisione di Cardiologia, Azienda Ospedale San Martino, Genova, Italy.
Kidney Int. 2000 Jul;58(1):260-8. doi: 10.1046/j.1523-1755.2000.00161.x.
Left ventricular hypertrophy (LVH) is highly prevalent in the dialyzed population, possibly because of inadequate diagnosis and therapy of arterial hypertension. The purpose of this study was to ascertain the adequacy of our approach in correctly identifying and treating arterial hypertension in our dialysis center.
Fifty-five dialyzed uremics were studied by continuous ambulatory blood pressure (BP) monitoring, which started before a single hemodialysis (HD) session, continued for 24 hours after HD ended, and was repeated for 15 minutes before the beginning of the next HD. Clinical pre-HD and post-HD routine BP measurements taken the month preceding BP monitoring were retrieved, and echocardiography was performed.
LVH was present in 46 out of 55 patients, and clinical pre-HD arterial hypertension was present in 36 out of 55. There were discrepancies between clinical and monitored BPs, mostly concerning diastolic pre-HD BP since BP readings were lower than monitored BP records (P < 0.0002). Although both clinical and monitored BPs bore strong direct correlations with the left ventricular mass (LVM), the closest correlations were those for monitored BP. Four groups of patients were identified by BP monitoring: group A (N = 14), with persistently normal BP, and group D (N = 13), with persistently supranormal BP levels. There were also two other groups (group B, N = 19; and group C, N = 9), whose BP values were high before HD, normalized after HD, and then increased again either soon after HD (group C) or later on following HD (group B). Monthly averaged clinical pre-HD mean BP values differed significantly among the four groups [91 +/- 10 (SD) mm Hg in group A, 101 +/- 7 in group B, 106 +/- 6 in group C, and 106 +/- 7 in group D; P < 0.0001, analysis of variance], as did their corresponding LVMs [132 +/- 27 g/m2 body surface area (BSA), 156 +/- 26, 201 +/- 51, and 200 +/- 36; P < 0.0001]. There were also differences in dialytic age, which was significantly longer in group A patients (109 +/- 54 months), who also tended to have higher, although not significantly higher, Kt/V(urea) values. No differences, however, were detected among the groups as far as type, dosages, and number of antihypertensive drugs given to each individual patient.
The high prevalence of LVH in the dialysis population might be the result of inadequate diagnosis and therapy of arterial hypertension. Arterial hypertension, in fact, was insufficiently treated in our dialysis center, since patients with varying degrees of severity of both arterial hypertension and LVH were kept on antihypertensive therapy of similar strength. Undertreatment may have resulted from not having recognized and/or from having underestimated the severity of arterial hypertension since some clinical BPs were measured incorrectly. Reluctance to use more aggressive antihypertensive therapy might also result from the deceptive feeling of "normalized" BP that one has following volume unloading with dialysis. This causes both the BP to run out of control between dialyses and LVH to worsen.
左心室肥厚（LVH）在透析人群中非常普遍，可能是由于动脉高血压的诊断和治疗不足。本研究的目的是确定我们在透析中心正确识别和治疗动脉高血压的方法是否恰当。
对55例透析尿毒症患者进行动态血压监测，在单次血液透析（HD）治疗前开始监测，HD结束后持续24小时，并在下一次HD开始前重复15分钟。检索血压监测前一个月临床HD前和HD后的常规血压测量值，并进行超声心动图检查。
55例患者中有46例存在LVH，55例中有36例临床HD前存在动脉高血压。临床血压和监测血压之间存在差异，主要涉及HD前舒张压，因为血压读数低于监测血压记录（P < 0.0002）。尽管临床血压和监测血压均与左心室质量（LVM）呈强正相关，但与监测血压的相关性最密切。通过血压监测将患者分为四组：A组（N = 14），血压持续正常；D组（N = 13），血压持续高于正常水平。还有另外两组（B组，N = 19；C组，N = 9），其血压值在HD前较高，HD后恢复正常，然后在HD后不久（C组）或稍后（B组）再次升高。四组患者每月平均临床HD前平均血压值差异显著[A组为91 ± 10（标准差）mmHg，B组为101 ± 7，C组为106 ± 6，D组为106 ± 7；P < 0.0001，方差分析]，其相应的LVMs也有差异[132 ± 27 g/m²体表面积（BSA），156 ± 26，201 ± 51，200 ± 36；P < 0.0001]。透析年龄也存在差异，A组患者的透析年龄明显更长（109 ± 54个月），他们的Kt/V（尿素）值也往往更高，尽管差异不显著。然而，在给予每位患者的抗高血压药物类型、剂量和数量方面，各组之间未检测到差异。
透析人群中LVH的高患病率可能是动脉高血压诊断和治疗不足的结果。事实上，我们的透析中心对动脉高血压的治疗不足，因为不同程度的动脉高血压和LVH患者都接受了强度相似的抗高血压治疗。治疗不足可能是由于未认识到和/或低估了动脉高血压的严重程度，因为一些临床血压测量不正确。不愿使用更积极的抗高血压治疗也可能是由于透析后容量清除导致血压“正常化”的错觉。这导致透析间期血压失控和LVH恶化。
