血液透析期间右心室游离壁应变的动态变化可识别有透析中低血压风险的患者

摘要(中文译文)

透析中低血压（IDH）是血液透析常见的并发症，与不良心血管后果相关。右心室（RV）功能储备对透析期间血流动力学稳定性的贡献尚不清楚。我们研究了右心室应变的动态变化是否与IDH相关。在这项前瞻性单中心研究中，50例接受维持性血液透析的终末期肾病患者在透析前和透析后即刻接受了全面的超声心动图检查及斑点追踪分析。IDH定义为透析前至透析后收缩压（SBP）下降≥20 mmHg。右心室游离壁应变（RVFWS）由一名设盲的专家离线分析。比较了发生与未发生IDH患者之间RVFWS的变化，并评估了SBP变化与RVFWS变化之间的相关性。在纳入分析的33例患者中，15例（45%）发生了IDH。两组间的基线临床特征、超滤量（平均2.9 L）及透析前SBP相当。大多数患者左心室射血分数保留，基线RVFWS无显著差异。然而，IDH组透析后RVFWS的下降幅度显著大于非IDH组（-7.0 ± 7.2% vs. -1.7 ± 4.6%，= 0.017）。此外，SBP下降幅度与RVFWS下降呈中度相关（= 0.50，= 0.003）。受试者工作特征分析提示，透析引起的RVFWS变化对IDH具有中等程度的判别能力（曲线下面积0.74；95%置信区间0.56-0.92）。尽管基线右心室功能相似，IDH仍与透析引起的RVFWS更大下降相关，提示急性容量卸载可能揭示右心室收缩储备受损。这些发现提供了初步证据，表明动态右心室应变评估有助于识别易发生透析中血流动力学不稳定的患者，值得在更大规模的研究中进一步验证。

Abstract

Intradialytic hypotension (IDH) is a frequent complication of hemodialysis that is associated with adverse cardiovascular consequences. The contribution of right ventricular (RV) functional reserve to hemodynamic stability during dialysis remains unclear. We investigated whether dynamic changes in RV strain are associated with IDH. In this prospective single-center study, 50 patients with end-stage renal disease undergoing maintenance hemodialysis underwent comprehensive echocardiography with speckle-tracking analysis immediately before and after dialysis. IDH was defined as a decrease in systolic blood pressure (SBP) of ≥ 20 mmHg from pre- to post-dialysis. Right ventricular free wall strain (RVFWS) was analyzed offline by a blinded specialist. Changes in RVFWS were compared between patients with and without IDH, and correlations between SBP change and RVFWS change were assessed. In the analyzed 33 patients, 15 patients (45%) developed IDH. Baseline clinical characteristics, ultrafiltration volume (mean, 2.9 L), and pre-dialysis SBP were comparable between groups. Left ventricular ejection fraction was preserved in most patients, and baseline RVFWS did not differ significantly. However, the IDH group showed a significantly greater post-dialysis reduction in RVFWS than the non-IDH group (-7.0 ± 7.2% vs. -1.7 ± 4.6%, = 0.017). Moreover, the magnitude of SBP decline correlated moderately with the decrease in RVFWS ( = 0.50, = 0.003). Receiver operating characteristic analysis suggested a modest discriminatory ability of dialysis-induced changes in RVFWS for IDH (area under the curve, 0.74; 95% confidence interval, 0.56-0.92). IDH was associated with a greater dialysis-induced decline in RVFWS despite similar baseline RV function, suggesting that acute volume unloading may unmask impaired RV contractile reserve. These findings provide preliminary evidence that dynamic RV strain assessment could help identify patients vulnerable to intradialytic hemodynamic instability, warranting further validation in larger studies.

如何引用