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

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林盈光(Ying-Kuang Lin) 查詢紙本館藏

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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
ii
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.
iv
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
vii
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

推文