Kooman Jeroen P, Katzarski Krassimir, van der Sande Frank M, Leunissen Karel M, Kotanko Peter
Division of Nephrology, Department of Internal Medicine, Maastricht University Medical Center, Maastricht, The Netherlands.
Dialysis Unit Solna Gate, Diaverum AB, and Division of Renal Medicine, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden.
Semin Dial. 2018 Sep;31(5):500-506. doi: 10.1111/sdi.12704. Epub 2018 Apr 19.
Hemodialysis (HD) is a lifesaving treatment for patients with end-stage renal disease, which is very efficient in the correction of abnormalities of the internal environment. However, this efficiency also induces significant hemodynamic, thermal, and respiratory stressors. These have parallels with the extreme physiologic demands which are normally mainly experienced by healthy subjects under adverse environmental conditions, with the difference that they must be endured by a vulnerable patient population. Hemodynamic stress induced by ultrafiltration leads to a decline in circulating blood volume, which may result in intradialytic hypotension (IDH) and changes in tissue perfusion, which may have long-term consequences for the function of vital organs such as the brain and the heart. Pronounced declines in central venous oxygen saturation have been observed during routine HD, which are related to the circulatory stress imposed upon the patient. Apart from patient-related factors, thermal stress induced by HD may lead to skin vasodilation, counteracting the normal hemodynamic response to hypovolemia, which has important pathophysiologic correlates in heat syncope. Lastly, respiratory stress is reflected by prolonged arterial hypoxemia during HD, which is both related to patient-related factors, but may also be partly because of the treatment itself, especially during the first 30-60 minutes. Whereas hypoxemia during HD is related to increased mortality, its role in the reduced tissue oxygen delivery during HD should be further defined. Treatment modifications, such as cool or temperature-controlled HD, may reduce circulatory and thermal stress, which also may translate into a reduced risk of long-term cardiac or cerebral damage. However, as circulatory stress is mainly time-dependent, prolonged, or more dialysis treatment may reduce the homeostatic burden on the patient.
血液透析（HD）是终末期肾病患者的一种挽救生命的治疗方法，在纠正内环境异常方面非常有效。然而，这种有效性也会引发显著的血流动力学、热和呼吸应激源。这些应激源与健康受试者在不利环境条件下通常主要经历的极端生理需求相似，不同之处在于它们必须由脆弱的患者群体来承受。超滤引起的血流动力学应激导致循环血容量下降，这可能导致透析中低血压（IDH）和组织灌注改变，这可能对大脑和心脏等重要器官的功能产生长期影响。在常规血液透析过程中观察到中心静脉血氧饱和度明显下降，这与施加在患者身上的循环应激有关。除了患者相关因素外，血液透析引起的热应激可能导致皮肤血管扩张，抵消对血容量不足的正常血流动力学反应，这在热晕厥中有重要的病理生理关联。最后，呼吸应激表现为血液透析期间动脉低氧血症持续时间延长，这既与患者相关因素有关，但也可能部分是由于治疗本身，尤其是在最初的30 - 60分钟内。虽然血液透析期间的低氧血症与死亡率增加有关，但其在血液透析期间组织氧输送减少中的作用应进一步明确。治疗调整，如采用低温或温度控制的血液透析，可能会降低循环和热应激，这也可能转化为降低长期心脏或脑部损伤的风险。然而，由于循环应激主要取决于时间，延长透析治疗时间或增加透析次数可能会减轻患者的内稳态负担。
