博碩士論文 104888003 詳細資訊




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姓名 林盈光(Ying-Kuang Lin)  查詢紙本館藏   畢業系所 跨領域轉譯醫學研究所
論文名稱 應用非侵入性方法來探究透析過程中血流動力學變化及心血管疾病之預後
(Application of Noninvasive Hemodynamic Parameters Monitored by Impedance Cardiography during Dialysis on Predicting Intra-dialytic and Long-term Adverse Cardiovascular Events in Patients with End-Stage Renal Disease)
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摘要(中) 血液透析的患者發生心管 疾病 和死亡的風險 非常 高,導致心血管 高,導致心血管 高,導致心血管 高,導致心血管 疾病 高發 生率 的因素很多,包括透析前收縮壓 的因素很多,包括透析前收縮壓 的因素很多,包括透析前收縮壓 的因素很多,包括透析前收縮壓 很高 或很低,透析中 ,透析中 ,透析中 發生 高血壓或低, 高血壓或低, 左心室肥大和自主神經 失調 。透析中 透析中 血壓的動態 變化 提供 了血液動力學 調節 之訊 息,並與死亡率 息,並與死亡率 息,並與死亡率 息,並與死亡率 有明顯 關聯。因此 。因此 透析過程中的血 液動力學 變化 提供了複雜的 血 壓調控機制 ,這反應了透析中身體水分 這反應了透析中身體水分 和滲透壓變化的重要信息,但 和滲透壓變化的重要信息,但 和滲透壓變化的重要信息,但 目前仍 了解 甚少。 甚少。 而阻抗心動 阻抗心動 描述 儀是一種有用的非侵入性方法, 是一種有用的非侵入性方法, 常用於評估血 液動力學參 數,例如 數,例如 數,例如 心搏輸出量 、心輸出量和血管阻力,可用於研究 心輸出量和血管阻力,可用於研究 心輸出量和血管阻力,可用於研究 血液 透析 過程中 的血液 動力學 變化 。然而 專注於透析 專注於透析 過程中 連續監 測血液動力學變 化之研究甚少 ,且尚 未有報導 這些 變化與 心血管疾病 之間的關係。 之間的關係。 因此 我們假設血液動力學調節異常 可能是 血液透析患者壓不穩定的主要原因,並且可能是 血液透析患者壓不穩定的主要原因,並且可能是 血液透析患者壓不穩定的主要原因,並且慢性腎衰竭 患者隨後發 生心血管疾病 的預後指標。 的預後指標。 我們 的研究 主要 是使用 阻抗心動 描述 儀來連續 監測血 液動力學 隨時間 之變化,並探討透析過程中這些量的調節。 研究 結果顯示 所有 患者於 透析 過程中 之平均 心搏輸出量 趨於下降。與沒有血 趨於下降。與沒有血 趨於下降。與沒有血 趨於下降。與沒有血 壓不穩定 的組別 相比,有血壓不穩定 相比,有血壓不穩定 相比,有血壓不穩定 的組別 和心臟衰竭的組別 在透析 過程中 的前 兩個階段之間的 心搏輸出量 變異係數 有顯著降低。 顯著降低。 我們也 發現 了非隨機性 心律指 數在組別與階段之間 有重要相互作用; 重要相互作用; 比起血壓不穩定或心 血壓不穩定或心 臟衰竭的患者 ,血壓 穩定的患者 非隨機性心律指數 明顯更高 ,而 透析 過程 早期和中對於 心律 的非隨 機性指標 可視為 血壓 穩定性的獨立預測因子。 穩定性的獨立預測因子。 經 2.5年追蹤觀察 ,無心血管 事件
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發生 的患者在透析 的患者在透析 的患者在透析 的患者在透析 的患者在透析 的患者在透析 過程中 過程中 過程中 的 第一小時和二之間的 第一小時和二之間的 第一小時和二之間的 第一小時和二之間的 第一小時和二之間的 第一小時和二之間的 第一小時和二之間的 第一小時和二之間的 第一小時和二之間的 第一小時和二之間的 第一小時和二之間的 第一小時和二之間的 第一小時和二之間心搏輸出量 心搏輸出量 心搏輸出量 心搏輸出量 心搏輸出量 變異係數 變異係數 變異係數 變異係數 和 心臟指數 變異係數 顯著增加。 顯著增加。 而透析 過程中 第一小時 和第二 小時之間 有較高的 心 搏輸出量 變異係數 和心臟指數 變異係數 者,其心血管事件發生率顯著降低 其心血管事件發生率顯著降低 。這些 血液動力學 的調控 機制可以作為 因心血管 事件 而住院 的獨立預測指標,這 的獨立預測指標,這 的獨立預測指標,這 也意味 著具有更好自 主調 控制系統的 患者可能具有更好心血管預後 。
摘要(英) Patients on hemodialysis are at high risk of cardiovascular events and mortality Many factors contribute to this high cardiovascular event rate, including a very low or high pre-dialysis systolic blood pressure, intra-dialytic hypertension or hypotension, left ventricular hypertrophy, and autonomic instability. The dynamics of intra-dialytic blood pressure (BP) provide additional information about the hemodynamic control system and are associated with mortality outcomes. Therefore, hemodynamic regulation during dialysis provides important information about the response of complex BP control mechanisms to continuous fluid shifts and changes in osmolarity, but remains poorly understood. Impedance cardiography (ICG) is a useful noninvasive method for the evaluation of hemodynamic parameters, such as stroke volume (SV), cardiac output (CO), and systemic vascular resistance (SVR), and could be used to investigate hemodynamic regulation during dialysis. However, changes in the regulation of hemodynamics during hemodialysis have not been investigated in patients with high mortality risk. In addition, few studies focused on continuously monitoring the hemodynamic variables other than BP during hemodialysis, and the relationship between the alteration of cardiovascular systems during hemodialysis and cardiovascular events is yet to be reported. We hypothesized that impaired regulation of hemodynamics could be a major reason for labile BP in patients on hemodialysis and it could be prognostic indicators for subsequent cardiovascular events in dialysis patients. The aims of this study were to monitor temporal variations in hemodynamic variables using ICG and to explore the regulation of these variables during dialysis.
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The average SV tended to decrease during hemodialysis in all study groups. A significant decrease was observed in the coefficient of variance (CoV) of SV between the first two stages of hemodialysis in patients with labile BP and congestive heart failure when compared to those without labile BP. Significant interactions between group and stage of the index of non-randomness for heart rate (HR) were also noted; this index was significantly higher in patients without labile BP than in those with labile BP or congestive heart failure. A greater difference between the early and middle stages of hemodialysis for non-randomness indexes of HR was an independent predictor of reduced BP lability during hemodialysis.
The CoV of SV and cardiac index (CI) between the 1st and 2nd hour of hemodialysis were significantly increased in patients without cardiovascular events compared to those with cardiovascular events. Higher CoV of SV and CI between the 1st and 2nd hour of hemodialysis were significantly correlated with longer cardiovascular event-free survival, and the area under the receiver operating characteristic curve showed fair overall discriminative power. The responses of hemodynamic control mechanisms can be independent predictive indexes for lower hospitalized cardiovascular events, which implies that these patients who have better autonomic control systems may have better cardiovascular outcomes.
關鍵字(中) ★ 慢性腎衰竭 關鍵字(英) ★ End-Stage Renal Disease
論文目次 中文摘要 中文摘要 ………………………………………………..…………….………………..i
Abstract……………………………………………………………..………………..iii
致謝 ……………………………………………………………………………………v
List of tables…………………………………………………………...…..…………ix
List of Figures……………………………………………………..…...…..…………x
List of abbreviations…………………………………………………………………xi
Chapter I Introduction……………………………………………………………….1
1.1 Motivation…………………………………………………………………………1
1.2 Objectives………………………………………………………………………….4
Chapter II Non-invasive Hemodynamic Profiles…………………………….……..5
2.1 Background………………………………………………………………………...5
2.2 Materials and methods……………………………………………..………………5
2.2.1 Study population……………………………………………...……………….5
2.2.2 Study design……………………………………………..………..…………..6
2.2.3 Analysis of temporal changes in hemodynamics……………………………..6 2.2.4 Information-based similarity…………………….……...……..…………….10
2.2.5 Statistical analysis………………………..……….……………...…………..12
2.3 Results……………………………………………………………….……………13
2.3.1 Patient demographics and clinical characteristics……………………………13
2.3.2 Association between variability in BP and cardiac function…….…………..14
2.3.3 Meaningful structure hidden beneath the dynamics of physiologic
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signals ……………………………………………………….…………….....18
2.4. Discussion…………………………………………….…………………..……..19
2.4.1 Relationship between BP lability, cardiac function, and hemodynamic
Parameters……………………….………………….………………………..20
2.4.2 Temporal changes in hemodynamic regulation during hemodialysis……….22
2.4.3 Study limitations……………………………………………….…………….23
2.4.4 Clinical applicability of study findings……………………..……………….24
2.5 Conclusions……………………………………………………….….….………..24
Chapter III Predict CV outcomes in ESRD…………………….………….………25
3.1 Background……………………………………………...………………………..25
3.2 Material and Methods…………………………………………………………….25
3.2.1 Study population……………………………………………………………..20
3.2.2 Study design……………………………………………...………………….26 3.2.3 Cardiovascular events………………………………………………………..27 3.2.4 Statistical analysis………………………………….………..……………….27
3.3 Results………………………………….………………………..…………..……28
3.3.1 Demographics of our patients………………………………………………..28
3.3.2 Continuous hemodynamics monitoring and their effects on CV outcomes…..31
3.3.3 Reduced CoV of SV and CI in early course of dialysis associated with poor CV outcomes……………………………………….…...………………32
3.4 Discussion…………………………………………………….….….…………36
3.5 Conclusions…………………………………..……………….….…………….40
Chapter IV Conclusions and Future Works……………………..………..……….41
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4.1 Conclusions…………………………………………………..…….……………..41
4.2 Future works……………………………………….……………………………..43
References……………………………………………………..…………………….44
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指導教授 林澂 審核日期 2020-8-10
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