Yanagiba S, Ando Y, Kusano E, Asano Y
Department of Nephrology, Jichi Medical School Hospital, Minamikawachi, Tochigi, Japan.
ASAIO J. 2001 Sep-Oct;47(5):528-32. doi: 10.1097/00002480-200109000-00026.
We have previously reported that the maximal inferior vena cava (IVC) diameter during quiet expiration (IVCe) measured by ultrasonography correlates well with the amount of body fluid, especially the circulating blood volume(2) and proposed using the criteria of IVC diameter to determine dry weight (DW) in anuric hemodialyzed (HD) patients: standard IVCe of pre- and post-HD are 14.9 +/- 0.4 and 8.2 +/- 0.3 mm, respectively (1). However, the same post-HD IVC criterion should not be applied to nonoliguric HD patients because it could result in rapid deterioration of residual renal function due to forced dehydration. Although the biochemical DW marker plasma atrial natriuretic peptide (ANP) is useful to evaluate hypervolemia but not hypovolemia, both hyper- and hypovolemia can be detected by IVC measurement. In the present study, we investigated whether the IVC diameter serves as an optimal evaluation of DW in nonoliguric HD (NO-HD) patients, avoiding not only overhydration but also dehydration. The IVCe and plasma ANP levels were measured in 14 euvolemic patients with chronic renal failure at conservative period (CP-CRF) and 11 NO-HD patients, in whom the average daily urine volume was more than 500 ml/day. In NO-HD patients, DW was adjusted to attain the euvolemic state with normotensive blood pressure, lack of edema, and lack of temporal oliguria after HD. The ANP in CP-CRF patients was 109.3 +/- 15.3 pg/ml, and pre- and post-HD ANP levels in NO-HD patients were 145.3 +/- 23.5 and 97.5 +/- 13.5 pg/ml, respectively. IVCe in CP-CRF was 13.4 +/- 0.9 mm, and pre- and post-HD IVCe in NO-HD patients were 14.2 +/- 1.0 mm and 11.9 +/- 0.9 mm, respectively. Although the post-HD IVCe was greater (i.e., less hypovolemic) than that in anuric HD patients, and close to the IVCe in CP-CRF, pre-HD IVCe was comparable with that in anuric HD patients. In addition, the pre-HD ANP level was no higher than that in CP-CRF. Thus, in NO-HD patients, the post-IVCe of 11.9 +/- 0.9 mm would be a marker for an appropriate DW setting avoiding severe post-HD dehydration as well as excessive hypervolemia during the interdialytic period.
我们之前曾报道，通过超声测量的安静呼气时的最大下腔静脉（IVC）直径（IVCe）与体液量，尤其是循环血容量密切相关(2)，并提出使用IVC直径标准来确定无尿血液透析（HD）患者的干体重（DW）：HD前和HD后的标准IVCe分别为14.9±0.4和8.2±0.3 mm(1)。然而，相同的HD后IVC标准不适用于非少尿型HD患者，因为这可能会因强制性脱水导致残余肾功能迅速恶化。虽然生化干体重标志物血浆心钠素（ANP）有助于评估高血容量但不能评估低血容量，但通过IVC测量可以检测到高血容量和低血容量。在本研究中，我们调查了IVC直径是否可作为评估非少尿型HD（NO-HD）患者干体重的最佳指标，既能避免过度水合也能避免脱水。对14例处于保守期（CP-CRF）的慢性肾衰竭血容量正常患者和11例平均每日尿量超过500 ml/天的NO-HD患者测量了IVCe和血浆ANP水平。在NO-HD患者中，调整干体重以达到血容量正常状态，即HD后血压正常、无水肿且无暂时性少尿。CP-CRF患者的ANP为109.3±15.3 pg/ml，NO-HD患者HD前和HD后的ANP水平分别为145.3±23.5和97.5±13.5 pg/ml。CP-CRF患者的IVCe为13.4±0.9 mm，NO-HD患者HD前和HD后的IVCe分别为14.2±1.0 mm和11.9±0.9 mm。虽然HD后的IVCe比无尿HD患者的更大（即低血容量更少），且接近CP-CRF患者的IVCe，但HD前的IVCe与无尿HD患者的相当。此外HD前的ANP水平不高于CP-CRF患者。因此，在NO-HD患者中，11.9±0.9 mm的HD后IVCe可作为一个指标，用于适当设定干体重，避免HD后严重脱水以及透析间期过度高血容量。
