Centro de Diálisis Los Llanos, Fundación Renal Íñigo Álvarez de Toledo (FRIAT), Madrid, España.
Servicio de Nefrología. Hospital Universitario Fundación Alcorcón, Madrid, España.
Nefrologia (Engl Ed). 2021 Jan-Feb;41(1):17-26. doi: 10.1016/j.nefro.2020.06.005. Epub 2020 Sep 16.
Hypertension is very common in haemodialysis (HD) patients, and is associated with increased morbidity and mortality rates. The goals of our research were to: 1. Measure blood pressure (BP) during HD sessions; 2. Study BP in between HD sessions with 44-hour Ambulatory Blood Pressure Monitoring (ABPM); 3. Identify differences between the BP recorded during HD and with the ABPM; 4. Evaluate changes in treatment after the ABPM; 5. Perform bioimpedance spectroscopy (BIS) on all patients and, in those hyper-hydrated or hypertensive according to ABPM, assess for changes in BP after adjusting the dry weight; 6. Identify factors associated with average systolic and diastolic BP measured by ABPM.
Prospective observational study, which included 100 patients from our dialysis unit. We measured BP before and after the HD sessions for two weeks and then, mid-week, we attached the ABPM device to the patients for 44 hours. Before starting the following dialysis session, we performed BIS. A second ABPM was performed on hyper-hydrated patients and patients hypertensive according to ABPM to evaluate changes in BP values.
According to the ABPM, 65% of patients had daytime BP > 135/85 mmHg, 90% night-time BP > 120/70 mmHg and 76% average BP > 130/80 mmHg; 11% had a dipper pattern, 51% non-dipper and 38% riser. The average systolic and diastolic BP readings were 4.7 mmHg (3.8%) and 1.1 mmHg (1.64%) higher on the second day. The dose of antihypertensive medication had to be lowered in 6% of patients, 9% had to stop taking it, 28% needed increased doses and 17% had to add a new drug. The pre-HD diastolic BP best matched the ABPM. After performing the bioimpedance and adjusting dry weight, there was a statistically significant decrease in all BP values. The univariate analysis showed that the average systolic BP was higher in patients with a high-calcium dialysis bath, more antihypertensive drugs and higher doses of EPO. The multivariate analysis showed significant association for EPO and number of drugs (p < 0.01). The average diastolic BP was higher in younger patients and patients with lower Charlson index, lower body mass index and less diuresis, those on higher doses of EPO and non-diabetics. The linear regression study showed age (p < 0.005), body mass index (p < 0.03) and EPO (p < 0.03) as significant variables.
Our study shows: 1. The variability of hypertension criteria according to use of BP values from during the HD session or ABPM; 2. The variability of BP in the interdialysis period; 3. That the pre-dialysis diastolic BP best corresponds with the ABPM. 4. That the use of both BIS and ABPM improves the control of BP; 5. That the dose of EPO is the most important factor associated with hypertension in our patients.
高血压在血液透析（HD）患者中非常常见，与发病率和死亡率的增加有关。我们研究的目的是：1. 测量 HD 期间的血压（BP）；2. 使用 44 小时动态血压监测（ABPM）研究 HD 期间的 BP；3. 确定 HD 期间记录的 BP 与 ABPM 之间的差异；4. 评估 ABPM 后治疗的变化；5. 对所有患者进行生物阻抗谱（BIS）检查，对于根据 ABPM 出现血容量过多或高血压的患者，评估调整干体重后的 BP 变化；6. 确定与 ABPM 测量的平均收缩压和舒张压相关的因素。
这是一项前瞻性观察研究，纳入了我们透析单位的 100 名患者。我们在两周内测量了 HD 前后的 BP，然后在周中为患者佩戴 ABPM 设备 44 小时。在开始下一次透析治疗之前，我们进行了 BIS。对根据 ABPM 出现血容量过多或高血压的患者进行第二次 ABPM，以评估 BP 值的变化。
根据 ABPM，65%的患者日间 BP > 135/85mmHg，90%夜间 BP > 120/70mmHg，76%平均 BP > 130/80mmHg；11%为杓型，51%非杓型，38%为晨峰型。第二天，平均收缩压和舒张压读数分别升高了 4.7mmHg（3.8%）和 1.1mmHg（1.64%）。6%的患者需要降低降压药剂量，9%的患者需要停止服用，28%的患者需要增加剂量，17%的患者需要添加新药。HD 前的舒张压与 ABPM 最匹配。进行生物阻抗测量并调整干体重后，所有 BP 值均有统计学意义的下降。单因素分析显示，高钙透析液、更多降压药和更高剂量 EPO 的患者平均收缩压更高。多因素分析显示 EPO 和药物数量有显著相关性（p < 0.01）。年轻患者、Charlson 指数较低、体重指数较低、利尿剂较少、EPO 剂量较高和非糖尿病患者的平均舒张压较高。线性回归研究表明年龄（p < 0.005）、体重指数（p < 0.03）和 EPO（p < 0.03）是显著变量。
我们的研究表明：1. 根据使用 HD 期间或 ABPM 期间的 BP 值确定高血压标准的可变性；2. 透析期间血压的可变性；3. HD 前的舒张压与 ABPM 最匹配。4. 同时使用 BIS 和 ABPM 可改善 BP 控制；5. 在我们的患者中，EPO 剂量是与高血压相关的最重要因素。
