| BackgroundAccording to the US epidemiological survey,in 2009,more than half of the MHD patients are elderly people.People over 65 years old accounted for 10.4% of hemodialysis patients,and patients over 75 years old had a higher incidence.The annual mortality rate of elderly hemodialysis patients ranges from 26% to 58%.Studies have shown that the incidence of cardiovascular events increased linearly with age.The mortality risk of cardiovascular events in elderly dialysis patients was more than 1 times higher than that in non-elderly patients.Hypertension is a risk factor for cardiovascular events and increased mortality in hemodialysis patients.Studies have shown that blood pressure before and after dialysis can not adequately diagnose and evaluate the condition of hypertension in hemodialysis patients.Ambulatory blood pressure monitoring during dialysis can provide real and detailed blood pressure level and diurnal variation of patients during dialysis.It has important clinical value in predicting target organ damage and cardiovascular events.ObjectiveThe purpose of this study is to observe the blood pressure level and the characteristics of circadian rhythm changes during dialysis in elderly hemodialysis patients,and to explore the factors leading to abnormal circadian rhythm,in order to effectively control the blood pressure of elderly hemodialysis patients,reduce the mortality rate of elderly hemodialysis patients,improve clinical prognosis,reduce the incidence of cardiovascular events,so as to improve the life of elderly hemodialysis patients.MethodA total of 68 maintenance hemodialysis patients were selected from the Hemodialysis Center of the First Affiliated Hospital of Chengdu Medical College from June 2017 to November 2018.The parameters of ambulatory blood pressure were obtained by using44-hour ambulatory blood pressure monitoring during the dialysis interval.The clinical data of 68 patients with maintenance hemodialysis,such as age,sex,age of dialysis,EPO dosage,weight growth rate during dialysis,blood analysis,blood biochemistry,electrolyte and other laboratory examination indexes were collected before and after ambulatory blood pressure monitoring.According to the age of dialysis patients,they were divided into elderly and non-elderly dialysis patients.The general data,laboratory examination index,cardiac color ultrasound detection index and ambulatory blood pressure monitoring index of the two groups were analyzed,and the characteristics of ambulatory blood pressure in elderly hemodialysis patients were analyzed.According to nocturnal blood pressure decline rate,divided into non-spoon type and reverse spoon type.Blood pressure load value is greater than 40% and which is less than 40%.The nocturnal systolic blood pressure decline rate during dialysis interval was analyzed by multivariate regression analysis with the above observation index。Results1.1 Comparison of general data and blood biochemical indices between the elderly group and the non-elderly group.From June 2017 to November 2018,68 maintenance hemodialysis patients in the Hemodialysis Center of the First Affiliated Hospital of Chengdu Medical College were enrolled in the elderly group,male,female,non-elderly group,male,female,elderly group,52% of whom had dialysis for more than three years,non-elderly group,27% of whom had dialysis for more than three years,and elderly group,3-grade hypertension.49% and 32% in non-elderly group.It is suggested that the dialysis time of elderly patients is long and the proportion of severe hypertension is high.There was no statistical difference between the two groups in the general data of dialysis age,sex ratio and hypertension grade.There was no significant difference in total cholesterol,serum calcium,serum phosphorus,serum sodium,kt/v,IDWG,triglyceride and EPO dosage between the two groups(P > 0.05);compared with the non-elderly group,the hemoglobin and albumin in the elderly group were lower,and there were significant differences(P =0.036,P=0.016).Compared with the non-elderly group,the elderly group had higher parathyroid hormone level,blood phosphorus and body weight growth rate(313.13±161.683 vs 464.22±198.597,2.32±0.16 vs 2.09±0.09,3.54±2.07 vs 2.8±1.32).1.2 Comparison of cardiac structural and functional parameters between elderly and non-elderly patients.In comparison of cardiac structural and functional parameters between the two groups,the results showed that left ventricular hypertrophy(LVH)in the elderly group was higher than that in the non-elderly group(67.0% vs 32.4%,P = 0.036),with statistical significance.The values of LVDd,LVDs and LVMI in the elderly group were higher than those in the non-elderly group.It is suggested that the cardiac structure and function of the elderly patients with hemodialysis have more obvious changes.1.3 Comparison of ambulatory blood pressure parameters between elderly and non-elderly patientsThe mean systolic blood pressure and nocturnal systolic blood pressure in the elderly group were higher than those in the non-elderly group at 44 hours of dialysis,and the mean diastolic blood pressure,day and night at 44 hours of dialysis were lower than those in the elderly group.There were significant differences between the two groups.(146.3±14.5 vs 141.7±16.7 P=0.005,0.44±1.82 vs 0.05±0.01,P=0.001,77.3±11.8 vs 94.5±12.9,P=0.03,76.7±12.03 vs 93.6±13.2,P=0.07,77.7±13.02 vs97.3±13.05,P=0.02)2.1 Grouped according to ambulatory blood pressure monitoring indicators,the body weight gain and parathyroid hormone levels in the anti-spoon blood pressure group were higher than those in the non-spoon blood pressure group(3.24±2.07vs2.8+1.32,P=0.016,242.36±20.68pg/ml vs129.18 vs 26.26pg/ml,P=0.038),and the serum albumin level was lower in the anti-spoon blood pressure group than in the non-spoon blood pressure group.There was no statistical difference in serum creatinine,predialysis urea,blood calcium and age,incidence of left ventricular hypertrophy,sex ratio,dialysis age and general data of IDWG between the two groups(P > 0.05),but the incidence of left ventricular hypertrophy between the two groups was higher in the anti-spoon blood pressure group than in the non-spoon type group.2.2 There are 38 patients(55.8%)with blood pressure load(>40%)and 30 patients(44.2%)with blood pressure load(<40%),There was no statistical difference between the two groups in the above indicators(P > 0.05).2.3.The indexes of ambulatory blood pressure monitoring: With the nocturnal systolic blood pressure drop rate as dependent variable and the above indexes as independent variable,multivariate stepwise regression analysis was carried out.The results showed that there was a negative correlation between nocturnal diastolic blood pressure drop rate and parathyroid hormone(P=0.003),positive correlation with weight gain during dialysis(P=0.025),and negative correlation between nocturnal systolic blood pressure drop rate and serum albumin(P=0.028)Conclusion:1.Compared with ordinary MHD,elderly MHD patients are more likely to have volume overload,disorder of calcium and phosphorus metabolism,high PTH,target organ damage,high incidence of hypertension,especially systolic hypertension,and abnormal circadian rhythm of blood pressure.2.Parathyroid hormone level,serum albumin and serum calcium are independent risk factors for increased blood pressure and abnormal rhythm in elderly MHD patients during dialysis.Therefore,reasonable control of patients’ PTH,adequate dialysis to remove small and medium molecular toxins,improve patients’ nutritional status and raise serum albumin level,and appropriate adjustment of antihypertensive program can effectively control patients’ hypertension and reduce the occurrence of abnormal blood pressure rhythm,thereby reducing the occurrence of cardiovascular events. |
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