一氧化氮生成增加可能与维持性血液透析期间的急性低血压有关。

Nishimura M, Takahashi H, Maruyama K, Ohtsuka K, Nanbu A, Hara K, Yoshimura M

Department of Clinical and Laboratory Medicine, Kyoto Prefectural University of Medicine, Japan.

Am J Kidney Dis. 1998 May;31(5):809-17. doi: 10.1016/s0272-6386(98)70050-2.

To investigate the possible involvement of endogenous nitric oxide (NO) in acute hypotension during maintenance hemodialysis, we measured the plasma concentration of the nitrate anion NO3-, a stable metabolite of NO, in 19 patients undergoing hemodialysis. We analyzed heart rate variability to estimate the relationship between autonomic nervous activity and NO production, low-frequency/high-frequency components (L/H) as a parameter of cardiac sympathetic activity, and high-frequency power as a parameter of cardiac vagal activity. Six patients developed severe hypotension (a change in mean blood pressure during dialysis > or = 20 mm Hg), four patients developed mild hypotension (a change in mean blood pressure < or = 19 mm Hg and > or = 1 mm Hg), and nine patients did not develop hypotension. The plasma levels of NO3- before dialysis were markedly elevated in the severely hypotensive group compared with the patients who showed no hypotension (566+/-122 micromol/L v 133+/-38 micromol/L; P < 0.01), and this difference disappeared midhemodialysis and after hemodialysis. The plasma concentration of NO3- before dialysis was significantly associated with both the change in mean blood pressure during dialysis (r= -0.735; P = 0.003) and the mean blood pressure after dialysis (r = -0.675; P = 0.0015). The L/H ratio was inhibited before or after dialysis in the severely hypotensive group compared with the nonhypotensive group, and hypotension during dialysis was correlated with the inhibited L/H ratio before (r = 0.784; P = 0.001) or after (r = 0.822; P = 0.001) dialysis. Plasma NO3- concentrations were correlated with the L/H ratio before (r = -0.553; P = .014) or after (r = -0.546; P = 0.015) dialysis. These results suggest that inhibited sympathetic activity is one of the causes of acute hypotension during dialysis, and the enhanced production of NO is involved in this inhibition of the sympathetic activity in patients having a hypotensive episode during dialysis. The plasma concentration of NO3- before dialysis may be a predictor of the risk of hypotension during dialysis in patients with end-stage renal disease.

为研究内源性一氧化氮（NO）在维持性血液透析期间急性低血压中可能的作用，我们测定了19例接受血液透析患者血浆中NO稳定代谢产物硝酸根阴离子（NO3-）的浓度。我们分析心率变异性以评估自主神经活动与NO生成之间的关系，将低频/高频成分（L/H）作为心脏交感神经活动的参数，高频功率作为心脏迷走神经活动的参数。6例患者发生严重低血压（透析期间平均血压变化≥20 mmHg），4例患者发生轻度低血压（平均血压变化＜19 mmHg且≥1 mmHg），9例患者未发生低血压。与未发生低血压的患者相比，严重低血压组透析前血浆NO3-水平显著升高（566±122 μmol/L对133±38 μmol/L；P＜0.01），且这种差异在透析中期和透析后消失。透析前血浆NO3-浓度与透析期间平均血压变化（r = -0.735；P = 0.003）及透析后平均血压（r = -0.675；P = 0.0015）均显著相关。与非低血压组相比，严重低血压组透析前或透析后L/H比值受到抑制，且透析期间低血压与透析前（r = 0.784；P = 0.001）或透析后（r = 0.822；P = 0.001）受抑制的L/H比值相关。血浆NO3-浓度与透析前（r = -0.553；P = 0.014）或透析后（r = -0.546；P = 0.015）的L/H比值相关。这些结果表明，交感神经活动受抑制是透析期间急性低血压的原因之一，NO生成增加参与了透析期间发生低血压事件患者交感神经活动的这种抑制。透析前血浆NO3-浓度可能是终末期肾病患者透析期间低血压风险的预测指标。