| Objective: cardiovascular disease is the leading cause of death in hemodialysis patients,and the mortality rate of cardiovascular disease in dialysis patients is as high as 51%.A large number of studies have confirmed that hemodialysis patients accompanied by hypertension,circadian rhythm of blood pressure and other abnormal blood pressure.High blood pressure is the main complication of hemodialysis patients(incidence about 80%),is the first risk factor for cardiovascular disease.Hypertension is an independent risk factor for congestive heart failure,ischemic heart disease and left ventricular hypertrophy,and can significantly increase the prevalence and mortality of cardiovascular disease.The circadian rhythm of blood pressure reflects abnormal blood pressure fluctuations,the nocturnal blood pressure decline rate(day and night average mean difference / day mean)< 10% is defined as the rhythm disappeared,called non dipper type blood pressure.In China hemodialysis patients,nocturnal non dipper blood pressure has a high rate of 90.3%,Xiao Qingxuan and other research datas show that the incidence rate of non dipper blood pressure was 70%.Non dipper blood pressure is a risk factor of left ventricular hypertrophy and other cardiovascular complications(such as intracranial hemorrhage,cardiac arrest and cerebral vascular injury).The abnormal blood pressure in hemodialysis patients is of great significance to the treatment and prognosis of patients,which suggests that the blood pressure monitoring is of great significance in the dialysis process.There are 3 ways of blood pressure monitoring in hemodialysis patients: monitoring of blood pressure during dialysis(including conventional regular blood pressure monitoring the blood pressure before dialysis,dialysis and blood pressure during dialysis);ambulatory blood pressure monitoring(ABPM);home blood pressure monitoring(HBPM).Ambulatory blood pressure monitoring can provide the following information: 1)the level of blood pressure,nighttime blood pressure,daytime blood pressure and blood pressure of 24h;2)nocturnal blood pressure decline rate;3)blood pressure: nocturnal blood pressure load,daytime blood pressure load and 24 h load of blood pressure;4)blood pressure variability: nocturnal blood pressure variability,day blood pressure variability and blood pressure mutation rate in 24 h.Comprehensive and accurate assessment of blood pressure in patients with white coat hypertension.In clinical practice,ABPM has been paid more attention by cardiovascular department,and the Department of Nephrology has gradually realized the value of ABPM in hypertension combined with various risk factors.In this study,we want to explore the method to reduce the risk of cardiovascular disease in maintenance hemodialysis(MHD)patients.By continuous monitoring the blood pressure changes and rhythm of patients about 24 hours during dialysis interval,using above results to guide the use of antihypertensive drug varieties and dosage,to adjust medication dose reasonably,which finally can help control patients' blood pressure better and help improve the quality of life of patients.Method:(1)Research objects and information Choose 40 MHD patients,they are all on diaysis in blood purification center of our hospital during a whole year of 2016.Their Clinical data,complications,dialysis schedule,blood pressure level,dosage and type of antihypertensive drugs used were recorded.(2)Grouping and research methods 1)Grouping and research ideas Objects were divided into two groups,.Two groups were no statistical differences(P>0.05)in age,gender,age,dialysis,level of blood pressure before dialysis cubital vein blood biochemical indexes(serum calcium,phosphorus,parathyroid hormone,hemoglobin,serum albumin).The Antihypertensive drug used by patients in controled group were adjusted according to the blood pressure values measured by dialysis day and dialysis interval.The observation group used 24 hours ambulatory blood pressure monitoring,and according to the monitoring results,to adjust the use of antihypertensive drugs.After 6 months,collected all patients' cubital artery blood before dialysis,tested the biochemical indexes(serum calcium,phosphorus,parathyroid hormone,hemoglobin,serum albumin)and used SF-36 scale to evaluate the quality of life of patients with MHD.2)Blood pressure monitoring and adjustment of medication The observation group is used ambulatory blood pressure monitoring to monitor 24 h ambulatory blood pressure during dialysis interval,Measuring once every 30 min,once every hour at night.Defined the day time from 6 to 22,the night time from 22 to the next day at 6.When blood pressure is measured,the patient is asked to stop exercising and the elbow is placed at the same level as the heart.According to ambulatory blood pressure monitor,collect the following parameters: the average systolic blood pressure of 24 hours and 24 hours average diastolic blood pressure,daytime average systolic blood pressure,daytime average diastolic blood pressure;the nighttime average systolic blood pressure,diastolic blood pressure at night.According to the 24 h ambulatory blood pressure monitoring,the mean blood pressure(including 24 hours,daytime,nighttime mean systolic blood pressure and mean diastolic blood pressure),and peak-to-valley ratio(T/P)were observed.According to the patients' blood pressure level,we adjusted the type of medication and medication time.If the patient is unwell,carry on ambulatory blood pressure monitoring again,adjust medication.Patients in control group were measured blood pressure at 6 hours,12 hours and 18 hours.If the patient is unwell,measure blood pressure again,adjust medication.3)Biochemical index detection Collected the cubital artery blood of the patients in the control group before dialysis;collected the cubital artery blood of the patients in the control group before dialysis after 6 months;collected the cubital artery blood of the patients in the observation group before dialysis;collected the cubital artery blood of the patients in the observation group before dialysis after 6 months.Testing blood calcium(Ca)and phosphorus(P),parathyroid hormone(PTH),hemoglobin(Hb),serum albumin(ALB)detection in above blood samples.4)Quality of life survey Use the SF-36 scale to investigate.When issuing a questionnaire,explained the purpose of the survey and how to fill out.with the approval of the patient,the respondents answered under the guidance of medical personnel.If he can't complete,he can choose to completed by the family assistance.2 weeks later,collecting the questionnaire and calculating scores.5)Cardiovascular events and mortality tracking Patients were followed up for 6 months after the completion of the study,and cardiovascular events and deaths were estimated.6)Statistical methods Enumeration data were compared by chi square test,using percentage and frequency.The measurement data using the mean and standard deviation(x±s)expressed.SPSS19.0 software was used for statistical analysis.,if conformed to normal distribution between groups,using t test,analysis and comparison between groups using single factor variance test standard was 0.05,two-sided test,P < 0.05 that the difference was statistically significant.Result:(1)The observation group after treatment followed by adjustment has an average decrease of 11.4/8.8mm Hg,compared with the control group significantly.From the two groups of blood pressure decline in the proportion of effective statistics,we can conclude the blood pressure of the observation group improved significantly.(2)According to the results of ambulatory blood pressure monitoring,adjusted the drug using,and sustained for 6 months.There is no significant difference in serum calcium,serum phosphorus,parathyroid hormone,and no significant level of serum albumin,hemoglobin(P>0.05)between the control group and the observation group.There is little change of the biochemical index between our first testing results and testing results after 6 months in both group,but the change has no statistical significance.(3)SF-36 scale to evaluate the health related quality of life(HRQOL)of the 8 aspects: physiological function(PF),Role-Physical(RP),bodily pain(BP),general health(CH),energy(VT),social function,emotional function(SF)(RE),mental health(MH).Compared with the control group,the observation group was significantly improved in the two aspects:general health and energy.But improvements in other areas are not significant.(4)Follow-up 6 months later in the observation group,3 cases were hospitalized due to subarachnoid hemorrhage,acute left heart failure,gastrointestinal bleeding,and the patients with subarachnoid hemorrhage was died.6 patients in the control group were hospitalized,1 cases of acute myocardial infarction,2 cases of brain stem hemorrhage,acute cerebral infarction in 1 cases,1 cases of heart failure,upper gastrointestinal bleeding in 1 cases,3 cases of them were died.Conclusion: 1.Ambulatory blood pressure monitoring can be more comprehensive and accurate reflection of the patient's blood pressure level,for patients to control blood pressure to facilitate.In our study,ambulatory blood pressure monitoring significantly improved the efficiency of regulation.The average blood pressure of the observation of decreased by 11.4/8.8mm Hg.2.If the hypertension isn't caused by calcium or phosphate or PTH abnormalities although blood pressure decreased,the change of serum calcium and phosphorus,parathyroid hormone is not obvious,and the change of hemoglobin,serum albumin and hypertension are not related.3.By using ambulatory blood pressure monitoring to guide medication,we can improve the quality of life of dialysis patients,especially in the two aspects:general health and energy,can significantly improve.4.According to the results of follow-up,the incidence of cardiovascular events in the ambulatory blood pressure monitoring group was relatively low,and the mortality rate decreased. |
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