维持性血液透析中低血压风险预测的Meta建模及验证

doi:10.3761/j.issn.0254-1769.2024.21.008

摘要/Abstract

摘要：

目的基于Meta建模构建维持性血液透析中低血压（intradialytic hypotension，IDH）风险预测模型并进行验证。方法检索Cochrane Library、PubMed、Web of Science、EBSCO、Scopus、CINAHL、中国知网、万方数据库自建库至2023年3月31日报告IDH危险因素的文献。使用随机效应模型合并OR值，筛选P<0.05的因素并通过其β系数建立模型，选择286例血液透析患者作为验证集评估模型的区分度、校准度和临床实用度。结果共纳入39篇文献，涉及25 546例患者，选取14个影响因素用于构建风险预测模型。IDH发生风险得分=-0.301 × 男性+0.015 × 年龄+0.004 × 透析龄+0.988 × 合并糖尿病+0.730 × 合并心血管疾病-0.042 × 透析前舒张压+0.666 × 采用血液透析滤过模式+0.076 × 加热温度+0.159 × 超滤率+0.476 × 超滤量+1.024 × 透析间期体重增加+0.053 × 血清磷+0.023 × 血尿素氮+0.040 × β2微球蛋白，选择肾脏病预后质量倡议、透析中最低收缩压<90 mmHg（1 mmHg=0.133 kPa）、透析中收缩压下降≥20 mmHg及英国肾脏病协会指南定义的透析中低血压作为4种结局指标。IDH预测模型在4种结局指标的曲线下面积分别为0.830、0.648、0.647和0.763。校准曲线显示模型在前2种结局下预测与实际大致相符（χ²=14.824，P=0.064；χ²=12.016，P=0.149）。决策分析显示在所有定义下模型整体上比全部干预和全部不干预的策略有更好的净获益。结论该研究利用Meta建模开发的IDH风险预测模型预测性能良好，具有一定的临床应用价值。

关键词: 血液透析, 低血压, 预测模型, Meta分析, 护理

Abstract:

Objective Meta modelling was employed to develop a risk prediction model for intradialytic hypotension（IDH） and validate the model. Methods Literature on risk factors for IDH published up to March 31，2023 was retrieved from 8 databases，including Cochrane Library，PubMed，Web of Science，EBSCO，Scopus，CINAHL，CNKI and Wanfang Database. Random effects model was used to combine ORs，and factors with P<0.05 were selected to establish the model based on their regression coefficients. 286 maintenance hemodialysis patients were selected as a validation cohort to evaluate the model’s discrimination，calibration and clinical utility. Results 39 studies were included，involving 25 546 patients. 14 factors were identified to establish the risk prediction model. The risk score for IDH occurrence was calculated as -0.301 × male+0.015 × age+0.004 × dialysis vintage+0.988 × diabetes+0.730 × cardiovascular disease-0.042 × predialysis systolic blood pressure+0.666 × dialysis mode of hemodialysis filter+0.076 × temperature+0.159 × ultrafiltration rate+0.476 × ultrafiltration volume+1.024 × weight gain between dialysis+0.053 × serum phosphorus+0.023 × blood urea nitrogen+0.040 × β₂-microglobulin. Definition in the Kidney Disease Outcomes Quality Initiative guideline，nadir intradialytic systolic blood pressure <90 mmHg（1 mmHg=0.133 kPa），falling intradialytic systolic blood pressure ≥20 mmHg，and definition in the United Kingdom Kidney Association guideline were selected as 4 outcomes. The areas under the curve for the prediction model with respect to these 4 outcomes were 0.830，0.648，0.647，and 0.763，respectively. Calibration curves showed that the model predictive outcomes were consistent with actual outcomes for the first 2 outcomes（χ²=14.824，P=0.064；χ²=12.016，P=0.149）. Decision curve analysis indicated that the model had better net benefit compared to either intervention/no intervention for all definitions. Conclusion The IDH risk prediction model developed by meta-modeling in this study has good predictive performance and certain application value.

Key words: Hemodialysis, Hypotension, Prediction Model, Meta-Analysis, Nursing Care

吕桂兰, 曹虎男, 王浩, 樊蕊. 维持性血液透析中低血压风险预测的Meta建模及验证[J]. 中华护理杂志, 2024, 59(21): 2611-2619.

LÜ Guilan, CAO Hunan, WANG Hao, FAN Rui. Meta-modeling and validation of a risk prediction model for intradialytic hypotension in maintenance hemodialysis patients[J]. Chinese Journal of Nursing, 2024, 59(21): 2611-2619.

图/表 5

表1 PubMed检索策略

Table 1 Search strategies of PubMed

图1 文献筛选流程

Figure 1 Literature screening process

表2 纳入文献的基本特征及质量评价（n=39）

Table 2 Characteristic and quality assessment of included literature（n=39）

表3 风险预测模型纳入因素及赋分情况

Table 3 Factors included in the risk prediction model and scoring situation

图2 4种定义下透析中低血压发生风险预测模型的受试者操作特征曲线注：KDOQI为以肾脏病预后质量倡议的透析中低血压定义为结局指标；Nadir 90为以透析中最低收缩压<90 mmHg（1 mmHg=0.133 kPa）为结局指标；Fall 20为以透析中收缩压下降≥20 mmHg为结局指标；UKKA为以英国肾脏病协会指南的透析中低血压定义为结局指标；AUC为曲线下面积。

Figure 2 Receiver operating characteristic curves for the risk prediction model of intradialytic hypotension under 4 definitions

参考文献 55

[1]	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.
[2]	朱东阁, 王菊子, 赵倩, 等. 维持性血液透析患者透析中低血压风险预测模型的系统评价[J]. 中华护理杂志, 2024, 59(2):174-183. DOI URL
	Zhu DG, Wang JZ, Zhao Q, et al. Systematic review of risk prediction models for intradialytic hypotension in patients with maintenance hemodialysis[J]. Chin J Nurs, 2024, 59(2):174-183. DOI URL
[3]	卜黎静, 程飞儿, 张爱琴, 等. 危重症患者肠内营养喂养不耐受风险预测模型的构建及验证[J]. 中华护理杂志, 2024, 59(15):1877-1883. DOI URL
	Bu LJ, Cheng FE, Zhang AQ, et al. Development and validation of a prediction model for enteral feeding intolerance in critically ill patients[J]. Chin J Nurs, 2024, 59(15):1877-1883. DOI URL
[4]	Jiang WH, Wang JY, Shen XF, et al. Establishment and validation of a risk prediction model for early diabetic kidney disease based on a systematic review and meta-analysis of 20 cohorts[J]. Diabetes Care, 2020, 43(4):925-933. DOI PMID
[5]	Peterson J, Welch V, Losos M, et al. The Newcastle-Ottawa Scale(NOS) for assessing the quality of nonrandomised studies in meta-analyses[J]. Ottawa:Ottawa Hospital Research Institute, 2011, 2(1):1-12.
[6]	Sullivan LM, Massaro JM, D’Agostino RB Sr. Presentation of multivariate data for clinical use:the Framingham study risk score functions[J]. Stat Med, 2004, 23(10):1631-1660. DOI PMID
[7]	K/DOQI Workgroup. K/DOQI clinical practice guidelines for cardiovascular disease in dialysis patients[J]. Am J Kidney Dis, 2005, 45:16-153.
[8]	Cho A, Lee YK, Oh J, et al. The relationship between intradialytic hypotension and vascular calcification in hemodialysis patients[J]. PLoS One, 2017, 12(10):e0185846.
[9]	Mangoni AA, Hewitson CL, Woodman RJ, et al. Symmetric di-methylarginine is an independent predictor of intradialytic hypotension[J]. Am J Hypertens, 2008, 21(8):955-959.
[10]	Mactier R, Hoenich N, Breen C. Renal association clinical practice guideline on haemodialysis[J]. Nephron Clin Pract, 2011, 118(Suppl 1):c241-c286.
[11]	Allinovi M, Palazzini G, Lugli G, et al. Pre-dialysis B-line quantification at lung ultrasound is a useful method for evaluating the dry weight and predicting the risk of intradialytic hypotension[J]. Diagnostics, 2022, 12(12):2990.
[12]	Assayag M, Levy D, Seris P, et al. Relative change of protidemia level predicts intradialytic hypotension[J]. J Am Heart Assoc, 2020, 9(1):e014264.
[13]	Bossola M, Laudisio A, Antocicco M, et al. Intradialytic hypotension is associated with dialytic age in patients on chronic hemodialysis[J]. Ren Fail, 2013, 35(9):1260-1263. DOI PMID
[14]	Chang YM, Shiao CC, Chang KC, et al. Heart rate variability is an indicator for intradialytic hypotension among chronic hemo-dialysis patients[J]. Clin Exp Nephrol, 2016, 20(4):650-659.
[15]	Correa S, Pena-Esparragoza JK, Scovner KM, et al. Predictors of intradialytic symptoms:an analysis of data from the hemo-dialysis study[J]. Am J Kidney Dis, 2020, 76(3):331-339. DOI PMID
[16]	Deng F, Di WJ, Ma YX, et al. The relationship between prescription of ultrafiltration and intradialytic hypotension in Chinese hemodialysis patients[J]. Ann Palliat Med, 2021, 10(5):5316-5321.
[17]	Geng XM, Yu JB, Xu JR, et al. Role of magnesium in the risk of intradialytic hypotension among maintenance hemodialysis patients[J]. Hemodial Int, 2020, 24(3):351-358. DOI PMID
[18]	Kuipers J, Oosterhuis JK, Krijnen WP, et al. Prevalence of intradialytic hypotension,clinical symptoms and nursing interventions:a three-months,prospective study of 3818 haemodialysis sessions[J]. BMC Nephrol, 2016, 17:21.
[19]	Locatelli F, Altieri P, Andrulli S, et al. Hemofiltration and hemo-diafiltration reduce intradialytic hypotension in ESRD[J]. J Am Soc Nephrol, 2010, 21(10):1798-1807.
[20]	Mc Causland FR, Waikar SS. Association of predialysis calcu-lated plasma osmolarity with intradialytic blood pressure de-cline[J]. Am J Kidney Dis, 2015, 66(3):499-506. DOI PMID
[21]	McIntyre D, Havas K, Bonner A. Monitoring for intradialytic hypotension:an audit of nursing practice[J]. J Ren Care, 2021, 47(1):27-33.
[22]	Mizuiri S, Nishizawa Y, Doi T,et al. Coronary artery calcification is a risk factor for intradialytic hypotension in patients undergoing hemodialysis[J]. Hemodial Int,2022,26(3):335-344.
[23]	Ravi KS, Reeves PB, Correa S, et al. Predialysis serum phosphate and intradialytic hypotension[J]. Hemodial Int, 2022, 26(1):38-47.
[24]	Rocha A, Sousa C, Teles P, et al. Effect of dialysis day on intradialytic hypotension risk[J]. Kidney Blood Press Res, 2016, 41(2):168-174.
[25]	Sands JJ, Usvyat LA, Sullivan T, et al. Intradialytic hypotension:frequency,sources of variation and correlation with clinical outcome[J]. Hemodial Int, 2014, 18(2):415-422.
[26]	Son HE, Ryu JY, Lee K, et al. The importance of muscle mass in predicting intradialytic hypotension in patients undergoing maintenance hemodialysis[J]. Kidney Res Clin Pract, 2022, 41(5):611-622. DOI PMID
[27]	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 PMID
[28]	Thongdee C, Phinyo P, Patumanond J, et al. Ultrafiltration rates and intradialytic hypotension:a case-control sampling of pooled haemodialysis data[J]. J Ren Care, 2021, 47(1):34-42.
[29]	Yang KH, Cho S, Kim SR, et al. Serum phosphorus levels are associated with intradialytic hypotension in hemodialysis patients[J]. Nephron, 2021, 145(3):238-244.
[30]	Yu JB, Liu ZH, Shen B, et al. Intradialytic hypotension as an independent risk factor for long-term mortality in maintaining hemodialysis patients:a 5-year follow-up cohort study[J]. Blood Purif, 2018, 45(4):320-326.
[31]	Zoccali C, Tripepi G, Neri L, et al. Effectiveness of cold HD for the prevention of HD hypotension and mortality in the general HD population[J]. Nephrol Dial Transplant, 2023, 38(7):1700-1706.
[32]	曹虎男, 刘玉秀, 樊蕊, 等. 老年维持性血液透析患者透析中低血压的危险因素分析[J]. 中华肾脏病杂志, 2023, 39(2):101-111. DOI
	Cao HN, Liu YX, Fan R, et al. Analysis of risk factors for intradialytic hypotension in elderly maintenance hemodialysis patients[J]. Chin J Nephrol, 2023, 39(2):101-111. DOI
[33]	陈雪兰, 丘余良. 维持性血液透析患者频发透析中低血压的相关因素分析[J]. 中国现代医生, 2020, 58(23):110-112,117.
	Chen XL, Qiu YL. Analysis of related factors of frequent intradialytic hypotension in maintenance hemodialysis patients[J]. China Mod Dr, 2020, 58(23):110-112,117.
[34]	郭雪梅, 朱朕男, 罗佳懿, 等. 维持性血液透析患者透析中低血压风险预测模型的构建及验证[J]. 中国血液净化, 2022, 21(6):408-412.
	Guo XM, Zhu ZN, Luo JY, et al. Construction and validation of a prediction model for the risk of intradialytic hypotension in maintenance hemodialysis patients[J]. Chin J Blood Purif, 2022, 21(6):408-412.
[35]	何鑫, 詹亚, 张红, 等. 列线图模型对3906名血液透析患者透析中低血压发生风险的预测及评估[J]. 中国血液净化, 2022, 21(5):350-355.
	He X, Zhan Y, Zhang H, et al. Prediction and evaluation of intradialytic hypotension risk in 3,906 hemodialysis patients by a nomogram model[J]. Chin J Blood Purif, 2022, 21(5):350-355.
[36]	李鹏举, 刘凤菊. 维持性血液透析患者合并透析相关低血压的危险因素[J]. 国际移植与血液净化杂志, 2022, 20(5):9-12.
	Li PJ, Liu FJ. Risk factors for dialysis-related hypotension in maintenance hemodialysis patients[J]. Int J Transplant Hemo-purification, 2022, 20(5):9-12.
[37]	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. DOI URL
	Lin LS, He LF, Ying XH. Development of a risk prediction model for intradialytic hypotension in patients with maintenance hemodialysis[J]. Chin J Nurs, 2021, 56(10):1466-1471. DOI URL
[38]	罗平平, 张红梅. 透析前血浆渗透压对血液透析患者频发性透析中低血压的预测价值[J]. 中国血液净化, 2022, 21(2):103-106.
	Luo PP, Zhang HM. Predialysis plasma osmolality for the prediction of frequent-intradialytic hypotension in hemodialysis patients[J]. Chin J Blood Purif, 2022, 21(2):103-106.
[39]	马国婷, 马欣, 徐文彬, 等. 维持性血液透析患者透析中低血压风险预测模型研究[J]. 成都医学院学报, 2023, 18(1):122-127,136.
	Ma GT, Ma X, Xu WB, et al. Study on risk prediction models for intradialytic hypotension in maintenance hemodialysis patients[J]. J Chengdu Med Coll, 2023, 18(1):122-127,136.
[40]	潘璐璐, 何颖雪, 邵国建. 维持性血液透析患者发生透析中低血压的相关危险因素分析[J]. 浙江医学, 2019, 41(22):2421-2423,2437.
	Pan LL, He YX, Shao GJ. A study on the related risk factors for intradialytic hypotension in maintenance hemodialysis patients[J]. Zhejiang Med J, 2019, 41(22):2421-2423,2437.
[41]	秦明明, 张洪旭, 章超群, 等. 平均红细胞体积、红细胞分布宽度与血液透析患者透析中低血压的相关性分析[J]. 临床肾脏病杂志, 2022, 22(7):553-559.
	Qin MM, Zhang HX, Zhang CQ, et al. Relationships between mean red blood cell volume,red blood cell distribution width and intradialytic hypotension in hemodialysis patients[J]. J Clin Nephrol, 2022, 22(7):553-559.
[42]	任永强, 何光伦, 于桂巧, 等. 维持性血液透析诱发低血压的危险因素[J]. 武警医学, 2022, 33(10):869-872.
	Ren YQ, He GL, Yu GQ, et al. Risk factors of hypotension caused by maintenance hemodialysis[J]. Med J Chin People’s Armed Police Force, 2022, 33(10):869-872.
[43]	王仁伴, 胡文雯, 邵国建. 维持性血液透析患者透析中低血压发生的列线图预测模型构建与评估[J]. 现代实用医学, 2022, 34(4):439-441,473.
	Wang RB, Hu WW, Shao GJ. Construction and evaluation of a nomogram prediction model for the occurrence of intradialysis hypotension in maintenance hemodialysis patients[J]. Mod Pract Med, 2022, 34(4):439-441,473.
[44]	王欣, 曹艳佩, 杨晓莉, 等. 血液透析患者频发性透析中低血压发生情况和影响因素分析[J]. 中国实用护理杂志, 2019, 35(8):599-603.
	Wang X, Cao YP, Yang XL, et al. Analysis on the occurrence and influencing factors of frequent intradialytic hypotension in hemodialysis patients[J]. Chin J Pract Nurs, 2019, 35(8):599-603.
[45]	姚为华, 刁宗礼, 李霞, 等. 糖尿病患者血液透析中低血压的影响因素分析[J]. 中国血液净化, 2022, 21(5):346-349.
	Yao WH, Diao ZL, Li X, et al. The influencing factors for intradialytic hypotension in diabetic patients with maintenance hemodialysis[J]. Chin J Blood Purif, 2022, 21(5):346-349.
[46]	张红, 周培一, 党毅, 等. 透析间期体质量增长情况与透析性低血压的相关性分析[J]. 中国血液净化, 2020, 19(8):513-516.
	Zhang H, Zhou PY, Dang Y, et al. Correlation between interdialytic weight gain and intradialytic hypotension[J]. Chin J Blood Purif, 2020, 19(8):513-516.
[47]	祖源, 喻倩, 李寒, 等. 维持性血液透析患者高频透析相关低血压与透析后乳酸水平相关性研究[J]. 中国血液净化, 2019, 18(10):669-672.
	Zu Y, Yu Q, Li H, et al. The relationship between high frequency dialysis related intradialytic hypotension and post-dialysis lactic acid level in maintenance hemodialysis patients[J]. Chin J Blood Purif, 2019, 18(10):669-672.
[48]	Drury ER, Wu J, Gigliotti JC, et al. Sex differences in blood pressure regulation and hypertension:renal,hemodynamic,and hormonal mechanisms[J]. Physiol Rev, 2024, 104(1):199-251.
[49]	Nitta K, Masakane I, Hanafusa N, et al. Annual dialysis data report 2017,JSDT Renal Data Registry[J]. Ren Replace Ther, 2019, 5(1):53.
[50]	Flint AC, Conell C, Ren XS, et al. Effect of systolic and diastolic blood pressure on cardiovascular outcomes[J]. N Engl J Med, 2019, 381(3):243-251.
[51]	赵洁, 常红, 王晓娟, 等. 脑卒中患者静脉溶栓24小时内血压与出血的相关性研究[J]. 中华护理杂志, 2019, 54(7):981-984. DOI URL
	Zhao J, Chang H, Wang XJ, et al. Association between 24-hour blood pressure and bleeding complications in patients underwent intravenous thrombolysis[J]. Chin J Nurs, 2019, 54(7):981-984. DOI URL
[52]	Buchanan C, Mohammed A, Cox E, et al. Intradialytic cardiac magnetic resonance imaging to assess cardiovascular responses in a short-term trial of hemodiafiltration and hemodialysis[J]. J Am Soc Nephrol, 2017, 28(4):1269-1277. DOI PMID
[53]	Zhou C, Shi ZY, Ouyang N, et al. Hyperphosphatemia and cardiovascular disease[J]. Front Cell Dev Biol, 2021, 9:644363.
[54]	Hong CL, Zhu HP, Zhou XD, et al. Association of blood urea nitrogen with cardiovascular diseases and all-cause mortality in USA adults:results from NHANES 1999-2006[J]. Nutrients, 2023, 15(2):461.
[55]	Huang YX, Lin YF, Zhai XB, et al. Association of beta-2-microglobulin with coronary heart disease and all-cause mortality in the United States general population[J]. Front Cardiovasc Med, 2022, 9:834150.