Flythe Jennifer E, Chang Tara I, Gallagher Martin P, Lindley Elizabeth, Madero Magdalena, Sarafidis Pantelis A, Unruh Mark L, Wang Angela Yee-Moon, Weiner Daniel E, Cheung Michael, Jadoul Michel, Winkelmayer Wolfgang C, Polkinghorne Kevan R
University of North Carolina Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, UNC School of Medicine, Chapel Hill, North Carolina, USA; Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, North Carolina, USA.
Division of Nephrology, Stanford University School of Medicine, Palo Alto, California, USA.
Kidney Int. 2020 May;97(5):861-876. doi: 10.1016/j.kint.2020.01.046. Epub 2020 Mar 8.
Blood pressure (BP) and volume control are critical components of dialysis care and have substantial impacts on patient symptoms, quality of life, and cardiovascular complications. Yet, developing consensus best practices for BP and volume control have been challenging, given the absence of objective measures of extracellular volume status and the lack of high-quality evidence for many therapeutic interventions. In February of 2019, Kidney Disease: Improving Global Outcomes (KDIGO) held a Controversies Conference titled Blood Pressure and Volume Management in Dialysis to assess the current state of knowledge related to BP and volume management and identify opportunities to improve clinical and patient-reported outcomes among individuals receiving maintenance dialysis. Four major topics were addressed: BP measurement, BP targets, and pharmacologic management of suboptimal BP; dialysis prescriptions as they relate to BP and volume; extracellular volume assessment and management with a focus on technology-based solutions; and volume-related patient symptoms and experiences. The overarching theme resulting from presentations and discussions was that managing BP and volume in dialysis involves weighing multiple clinical factors and risk considerations as well as patient lifestyle and preferences, all within a narrow therapeutic window for avoiding acute or chronic volume-related complications. Striking this challenging balance requires individualizing the dialysis prescription by incorporating comorbid health conditions, treatment hemodynamic patterns, clinical judgment, and patient preferences into decision-making, all within local resource constraints.
血压（BP）和容量控制是透析治疗的关键组成部分，对患者症状、生活质量和心血管并发症有重大影响。然而，鉴于缺乏细胞外容量状态的客观测量方法，且许多治疗干预措施缺乏高质量证据，制定关于血压和容量控制的共识性最佳实践一直具有挑战性。2019年2月，改善全球肾脏病预后组织（KDIGO）召开了一次名为“透析中的血压与容量管理”的争议会议，以评估与血压和容量管理相关的当前知识状况，并确定改善接受维持性透析患者的临床和患者报告结局的机会。会议讨论了四个主要主题：血压测量、血压目标以及血压未达标的药物治疗；与血压和容量相关的透析处方；以基于技术的解决方案为重点的细胞外容量评估和管理；以及与容量相关的患者症状和体验。报告和讨论得出的总体主题是，透析中管理血压和容量涉及权衡多种临床因素和风险考量以及患者的生活方式和偏好，所有这些都在一个狭窄的治疗窗口内，以避免急性或慢性容量相关并发症。要达到这种具有挑战性的平衡，需要在当地资源限制范围内，通过将合并的健康状况、治疗血流动力学模式、临床判断和患者偏好纳入决策，来个体化透析处方。
