Hsu Hon-Chun, Robinson Chanel, Norton Gavin R, Woodiwiss Angela J, Dessein Patrick H
Cardiovascular Pathophysiology and Genomics Research Unit, School of Physiology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
Nephrology Unit, Milpark Hospital, Johannesburg, South Africa.
Int J Nephrol Renovasc Dis. 2020 Dec 30;13:385-395. doi: 10.2147/IJNRD.S285168. eCollection 2020.
It remains unclear why the optimal haemoglobin target is lower in patients with chronic kidney disease (CKD) than in non-CKD persons. Arteriosclerosis and consequent impaired arterial function comprise a central cardiovascular risk mechanism in CKD. We hypothesized that the optimal haemoglobin target depends on its opposing effects on arterial stiffness and pressure pulsatility in CKD.
Arterial stiffness (aortic pulse wave velocity), wave reflection (augmentation index, reflected wave pressure and reflection magnitude), and pressure pulsatility (central systolic and pulse pressure, peripheral pulse pressure, pressure amplification and forward wave pressure) were assessed in 48 dialysis patients.
In established confounder and diabetes adjusted linear regression models, haemoglobin levels were directly associated with arterial stiffness (partial R=0.366, p=0.03) and inversely with central systolic pressure (partial R=-0.344, p=0.04), central pulse pressure (partial R=-0.403, p=0.01), peripheral pulse pressure (partial R=-0.521, p=0.001) and forward wave pressure (partial R=-0.544, p=0.001). The presence of heart failure and use of angiotensin converting enzyme inhibitors or angiotensin receptor blockers and erythropoietin stimulating agents did not materially alter these relationships upon further adjustment for the respective characteristics in the models, and in sensitivity analyses. In receiver operator characteristic curve analysis, the optimal haemoglobin concentration cut-off values in predicting arterial stiffness and increased central pulse pressure were remarkably similar at 10.95 g/dl and 10.85 g/dl, respectively, and with clinically useful sensitivities, specificities and positive and negative predictive values. In logistic regression models, a haemoglobin value of >10.9 mg/dl was associated with both arterial stiffness (>10 m/sec; OR (95% CI) = 10.48 (1.57-70.08), p=0.02) and normal central pulse pressure (>50 mmHg; OR (95% CI) = 7.55 (1.58-36.03), p=0.01).
This study suggests that the optimal haemoglobin target in dialysis patients is ~11g/dl and determined by its differential and contrasting effects on arterial stiffness and pressure pulsatility.
目前尚不清楚为何慢性肾脏病（CKD）患者的最佳血红蛋白目标低于非CKD患者。动脉粥样硬化及随之而来的动脉功能受损是CKD患者心血管风险的核心机制。我们推测，最佳血红蛋白目标取决于其对CKD患者动脉僵硬度和压力波动性的相反作用。
对48例透析患者评估动脉僵硬度（主动脉脉搏波速度）、波反射（增强指数、反射波压力和反射幅度）以及压力波动性（中心收缩压和脉压、外周脉压、压力放大和前向波压力）。
在已校正混杂因素和糖尿病的线性回归模型中，血红蛋白水平与动脉僵硬度呈正相关（偏相关系数R=0.366，p=0.03），与中心收缩压呈负相关（偏相关系数R=-0.344，p=0.04），与中心脉压呈负相关（偏相关系数R=-0.403，p=0.01），与外周脉压呈负相关（偏相关系数R=-0.521，p=0.001），与前向波压力呈负相关（偏相关系数R=-0.544，p=0.001）。在校正模型中各自特征以及敏感性分析后，心力衰竭的存在、血管紧张素转换酶抑制剂或血管紧张素受体阻滞剂以及促红细胞生成素刺激剂的使用并未实质性改变这些关系。在受试者工作特征曲线分析中，预测动脉僵硬度和中心脉压升高时的最佳血红蛋白浓度临界值分别为10.95g/dl和10.85g/dl，具有临床可用的敏感性、特异性以及阳性和阴性预测值。在逻辑回归模型中，血红蛋白值>10.9mg/dl与动脉僵硬度（>10m/秒；比值比（95%可信区间）=10.48（1.57-70.08），p=0.02）和正常中心脉压（>50mmHg；比值比（95%可信区间）=7.55（1.58-36.03），p=0.01）均相关。
本研究表明，透析患者的最佳血红蛋白目标约为11g/dl，且由其对动脉僵硬度和压力波动性的不同及相反作用所决定。
