维持性血液透析患者透析中低血压风险预测模型的构建

doi:10.3761/j.issn.0254-1769.2021.10.004

摘要/Abstract

摘要：

目的分析维持性血液透析（maintenance hemodialysis,MHD）患者发生透析中低血压（intradialytic hypotension,IDH）的影响因素,构建MHD患者发生IDH的风险预测模型。方法选取福建省5所三级甲等医院行MHD的患者475例。通过Lasso回归筛选预测因子,采用多因素Logistic回归分析建立MHD患者发生IDH的风险预测模型,并使用列线图展示模型。采用ROC曲线、校准曲线评价模型的区分度及校准度,使用Bootstrap法对模型进行内部验证。结果身高、原发病类型、超滤量、透析前收缩压及近期（≤1个月）频发IDH是MHD患者发生IDH的影响因素。列线图模型的ROC曲线下面积为0.830,灵敏度为71.8%,特异度为79.9%,约登指数为0.517,内部验证C-统计量为0.814。结论该研究构建的模型预测效果较好,可为临床护理人员识别MHD患者发生IDH及实施预防性护理提供借鉴。

关键词: 血液透析, 低血压, 预测模型, 护理

Abstract:

Objective To explore risk factors of intradialytic hypotension（IDH） in patients with maintenance hemodialysis（MHD） and to develop a risk prediction model of it. Methods Totally 475 patients with MHD in 5 tertiary hospitals were selected. Lasso regression analysis was used to select predictors,and multivariate logistic regression analysis was used to develop the risk prediction model,and this was presented with nomogram. ROC curve and calibration curve were used to assess the discrimination and calibration of the model,and Bootstrap method was used for internal validation. Results The multivariate regression analysis showed that height,primary disease types,ultrafiltration,predialysis systolic blood pressure,and frequent intradialytic hypotension within 1 month were risk factors of IDH in patients with MHD. The area under the ROC curve of the nomogram model was 0.830,with the sensitivity of 71.8% and the specificity of 79.9%. The youden index was 0.517. The model internal verification showed the C-index of 0.814. Conclusion The model has satisfactory effects,which can provide references for nurses to identify high-risk patients and implement preventive care.

Key words: Hemodialysis, Hypotension, Prediction Model, Nursing Care

林丽桑, 何丽芳, 应秀红. 维持性血液透析患者透析中低血压风险预测模型的构建[J]. 中华护理杂志, 2021, 56(10): 1466-1471.

LIN Lisang, HE Lifang, YING Xiuhong. Development of a risk prediction model for intradialytic hypotension in patients with maintenance hemodialysis[J]. Chinese Journal of Nursing, 2021, 56(10): 1466-1471.

图/表 5

表1 患者的一般资料比较

Table 1 General information of the patients

图1 Lasso回归内部交叉验证图

Figure 1 Internal cross-validation of lasso regression

表2 自变量赋值情况

Table 2 The assignment of the independent variable

表3 维持性血液透析患者发生透析中低血压的Logistic回归分析

Table 3 Logistic regression analysis to predict intradialytic hypotension in patients with maintenance hemodialysis

图2 维持性血液透析患者发生透析中低血压风险预测模型的列线图注：1mmHg=0.133kPa。

Figure 2 Nomogramof intradialytic hypotension in patients with maintenance hemodialysis

参考文献 23

[1]	K/DOQI Workgroup. K/DOQI clinical practice guidelines for cardiovascular disease in dialysis patients[J]. Am J Kidney Dis, 2005, 45(suppl 3):S1-153.
[2]	Flythe JE, Xue H, Lynch KE, et al. Association of mortality risk with various definitions of intradialytic hypotension[J]. J Am Soc Nephrol, 2015, 26(3):724-734. DOI URL
[3]	Flythe JE, Chang TI, Gallagher MP, et al. Blood pressure and volume management in dialysis:conclusions from a Kidney Disease:Improving Global Outcomes(KDIGO) controversies conference[J]. Kidney Int, 2020, 97(5):861-876. DOI URL
[4]	Chang TI, Paik J, Greene T, et al. Intradialytic hypotension and vascular access thrombosis[J]. J Am Soc Nephrol, 2011, 22(8):1526-1533. DOI URL PMID
[5]	Stefánsson BV, Brunelli SM, Cabrera C, et al. Intradialytic hypotension and risk of cardiovascular disease[J]. Clin J Am Soc Nephrol, 2014, 9(12):2124-2132. DOI URL
[6]	Seong EY, Zheng Y, Winkelmayer WC, et al. The relationship between intradialytic hypotension and hospitalized mesenteric ischemia:a case-control study[J]. Clin J Am Soc Nephrol, 2018, 13(10):1517-1525. DOI URL
[7]	曾思. 透析中低血压发病机制及预后研究进展[D]. 重庆:重庆医科大学, 2020.
	Zeng S. Mechanisms and outcome progress of intradialytic hypotension[D]. ChongQing:ChongQing Medical University, 2020.
[8]	Kanbay M, Ertuglu LA, Afsar B, et al. An update review of intradialytic hypotension:concept,risk factors,clinical implications and management[J]. Clin Kidney J, 2020, 13(6):981-993. DOI URL
[9]	陈香美. 血液净化标准操作规程2020版[M]. 北京: 人民军医出版社, 2020.
	Chen XM. Blood purification standard operating procedure[M]. Beijing: People’s Military Medical Press, 2020.
[10]	翁佳敏, 黄碧红, 张炜晨, 等. 维持性血液透析患者残余肾功能与症状困扰关系的研究[J]. 中国血液净化, 2019, 18(8):524-526,534.
	Weng JM, Huang BH, Zhang WC, et al. The association between residual renal function and symptom burden in maintenance hemodialysis patients[J]. Chin J Blood Purif, 2019, 18(8):524-526,534.
[11]	Kuipers J, Oosterhuis JK, Krijnen WP, et al. Prevalence of intradialytic hypotension,clinical symptoms and nursing inter-ventions:a three-months,prospective study of 3818 haemodialysis Sessions[J]. BMC Nephrol, 2016, 17:21. DOI URL
[12]	中国血压测量指南[J]. 中华高血压杂志, 2011, 19(12):1101-1115.
	Guidelines for blood pressure measurement in China[J]. Chin J Hypertens, 2011, 19(12):1101-1115.
[13]	Dunlop JL, Vandal AC, Marshall MR. Low dialysate sodium levels for chronic haemodialysis[J]. Cochrane Database Syst Rev, 2019, 1：CD011204.
[14]	Tislér A, Akócsi K, Hárshegyi I, et al. Comparison of dialysis and clinical characteristics of patients with frequent and occasional hemodialysis-associated hypotension[J]. Kidney Blood Press Res, 2002, 25(2):97-102. DOI URL
[15]	Zitt E, Neyer U, Meusburger E, et al. Effect of dialysate temperature and diabetes on autonomic cardiovascular regulation during hemodialysis[J]. Kidney Blood Press Res, 2008, 31(4):217-225. DOI URL
[16]	Adler GK, Bonyhay I, Failing H, et al. Antecedent hypoglycemia impairs autonomic cardiovascular function:implications for rigorous glycemic control[J]. Diabetes, 2009, 58(2):360-366. DOI PMID
[17]	余金波. 血液透析患者透析中低血压的发病危险因素及其对预后影响的前瞻性队列研究[D]. 上海:复旦大学, 2012.
	Yu JB. The risk factors for intradialytic-hypotension and its impacts on the outcomes among maintenance hemodialysis patients:a prospective cohort study[D]. Shanghai:Fudan University, 2012.
[18]	Port FK, Hulbert-Shearon TE, Wolfe RA, et al. Predialysis blood pressure and mortality risk in a national sample of maintenance hemodialysis patients[J]. Am J Kidney Dis, 1999, 33(3):507-517. PMID
[19]	Rahman M, Fu P, Sehgal AR, et al. Interdialytic weight gain,compliance with dialysis regimen,and age are independent predictors of blood pressure in hemodialysis patients[J]. Am J Kidney Dis, 2000, 35(2):257-265. PMID
[20]	Takeda A, Toda T, Fujii T, et al. Can predialysis hypertension prevent intradialytic hypotension in hemodialysis patients?[J]. Nephron Clin Pract, 2006, 103(4):c137-c143. DOI URL
[21]	Kim SY, Hong YA, Yoon H E, et al. Vascular calcification and intradialytic hypotension in hemodialysis patients:clinical relevance and impact on morbidity and mortality[J]. Int J Cardiol, 2016, 217:156-160. DOI URL
[22]	徐林芳, 刘同强, 丁钟琴. 透析液温度对血液透析患者舒适状况的影响[J]. 中华护理杂志, 2012, 47(12):1069-1071.
	Xu LF, Liu TQ, Ding ZQ. The influence of dialysate temperature on the comfort of patients with hemodialysis[J]. Chin J Nurs, 2012, 47(12):1069-1071.
[23]	郭桂, 张海林, 尹丽霞, 等. 血液透析过程中患者发生饮食不良反应的影响因素分析[J]. 中华护理杂志, 2020, 55(6):877-883.
	Guo G, Zhang HL, Yi LX, et al. Analysis of the status and influencing factors of adverse dietary reactions in patients during hemodialysis[J]. Chin J Nurs, 2020, 55(6):877-883.