背景:N末端B型利钠肽前体(NT-proBNP)升高是血液透析开始不良结局的有效预测指标。这些患者经常经历透析中低血压,这可能部分反映了心脏功能障碍,但NT-proBNP与透析中低血压的相关性尚不清楚。
方法:我们对一项随机试验进行了事后分析,该试验在52名开始血液透析的患者中测试了甘露醇与安慰剂的比较(NCT01520207)。在第一次和第三次会议之前测量NT-proBNP(n=87)。混合效应模型(调整随机治疗,性别,种族,年龄,糖尿病,心力衰竭,导管使用,透析前收缩压,透析前体重,超滤量,血清钠,碳酸氢盐,尿素氮,磷酸盐,白蛋白,血红蛋白,和疗程长度)适合检查NT-proBNP与收缩压下降(透析前减去最低点收缩压)的相关性。此外,混合效应泊松模型适用于研究与透析中低血压(收缩压下降≥20mmHg)的相关性.
结果:平均年龄为55±16岁;33%有基线心力衰竭。NT-proBNP中位数为5498[2011年第25-75百分位数,14,790]pg/mL;26个疗程(30%)并发透析中低血压。在调整后的模型中,每单位较高的log-NT-proBNP与收缩压降低6.0mmHg相关(95CI-9.2~-2.8).透析前NT-proBNP较高,每个日志单元,与透析中低血压的风险降低52%相关(IRR0.48,95CI0.23-0.97),没有通过随机治疗改变效果的证据(P-交互作用=0.17)。
结论:在开始血液透析的患者中,较高的NT-proBNP与透析中收缩压下降较少以及透析中低血压风险较低相关.未来的研究应调查较高的透析前NT-proBNP水平是否可以确定可能耐受更积极的超滤的患者。
BACKGROUND: Elevated N-terminal pro B-type natriuretic peptide (NT-proBNP) is a potent predictor of adverse outcomes in hemodialysis initiation. These patients often experience intradialytic hypotension, which may partially reflect cardiac dysfunction, but the association of NT-proBNP with intradialytic hypotension is not clear.
METHODS: We performed a post hoc analysis of a randomized trial that tested mannitol versus placebo in 52 patients initiating hemodialysis (NCT01520207). NT-proBNP was measured prior to the first and third sessions (n = 87). Mixed-effects models (adjusting for randomized treatment, sex, race, age, diabetes, heart failure, catheter use, pre-dialysis systolic blood pressure, pre-dialysis weight, ultrafiltration volume, serum sodium, bicarbonate, urea nitrogen, phosphate, albumin, hemoglobin, and session length) were fit to examine the association of NT-proBNP with systolic blood pressure decline (pre-dialysis minus nadir systolic blood pressure). Additionally, mixed-effects Poisson models were fit to examine the association with intradialytic hypotension (≥20 mmHg decline in systolic blood pressure).
RESULTS: Mean age was 55 ± 16 years; 33% had baseline heart failure. The median NT-proBNP was 5498 [25th-75th percentile 2011, 14,790] pg/mL; 26 sessions (30%) were complicated by intradialytic hypotension. In adjusted models, each unit higher log-NT-proBNP was associated with 6.0 mmHg less decline in systolic blood pressure (95%CI -9.2 to -2.8). Higher pre-dialysis NT-proBNP, per log-unit, was associated with a 52% lower risk of intradialytic hypotension (IRR 0.48, 95%CI 0.23-0.97), without evidence for effect modification by randomized treatment (P-interaction = 0.17).
CONCLUSIONS: In patients initiating hemodialysis, higher NT-proBNP is associated with less decline in intradialytic systolic blood pressure and lower risk of intradialytic hypotension. Future studies should investigate if higher pre-dialysis NT-proBNP levels may identify patients who might tolerate more aggressive ultrafiltration.