认知行为干预对透析性低血压糖尿病肾病患者的影响

目的探讨认知行为干预对透析性低血压的糖尿病肾病患者的影响。方法将56例透析性低血压的糖尿病肾病患者按入院的先后顺序分为2组：观察组和对照组,每组28例。2组患者均控制血糖、平衡透析液、选择相容性较好的透析膜及严格控制体质量,并采用常规护理。在此基础上,观察组患者采用认知行为干预。观察2组患者干预前、干预6个月后临床疗效及生存的情况,并对2组患者干预前、干预6个月后采用抑郁自评量表（SDS）和焦虑自评量表（SAS）进行SDS、SAS评分。2组患者随访6个月~3年。结果观察组患者总有效率明显高于对照组（92.9%比75.0%,P〈0.05）,观察组患者干预6个月后SDS、SAS得评分均明显低于对照组（均P〈0.05）。观察组患者随访3年的生存率明显高于对照组（71.4%比42.9%,P〈0.05）。结论认知行为干预可明显提高透析性低血压的糖尿病肾病患者临床治疗效果,纠正不良情绪,改善远期预后。     

OPTIMIZED PROCEDURE TO EVALUATE THE THERMAL ENERGY TRANSFER IN HEMODIALYSIS TREATMENT

Hemodialysis treatment is biased by complications during its operative phases. One of these potential accidents consists in intradialytic hypotension, that causes discomfort to the patient and may even increase the risk of death. Therefore, it is very important to predict these events in routine clinical procedures. A cause of hypotension may be thermal energy/heat exchanges between extracorporeal system and the surrounding environment. A model to evaluate these heat losses is proposed and improved in order to maintain constant patient blood temperature. A convenient procedure is defined to improve and optimize clinical treatment. Although most hemodialysis machines automatically control the dialysate solution temperature starting from peripheral body temperature measurements, the proposed method is based on the control of the pre-dialysis core temperature of the patient, and the temperature of the blood entering the artery from the extracorporeal circuit after the treatment in the dialyzer. Measurements of arterial and venous blood temperatures are obtained in a non invasive way by a suitable estimate of the thermal energy exchanges between the blood and the environment during the extracorporeal recirculation. The suggested model guarantees a constant core temperature of the patient, improving prevention from intradialytic hypotension.     

A meta‐analysis of sodium profiling techniques and the impact on intradialytic hypotension

Introduction Hemodialysis has improved in recent years, however, despite such improvements, intra‐dialytic hypotensive episodes still persist which can lead to a reduction in the overall effectiveness of the treatment. Profiling sodium levels during dialysis can improve vascular refilling and therefore may prevent hypotensive events. A number of profiling methods exist and this meta‐analysis set out to examine the effectiveness of these methods. Methods To assess the effectiveness of hemodialysis sodium profiling techniques. A review and meta‐analysis analytical framework was used. A search was conducted using Medline, Embase and CINAHL, Scopus and Web of Knowledge between 1946 and 2014 of published English‐language peer reviewed randomized control studies. In total 10 articles were retrieved and included in the review. All data was abstracted with a standardized data collection form. Stata 11.2 (Stata Corp) was used to analyse the data. Actual numbers of hypotensive events were pooled between studies. Analysis of subgroups was performed on sodium profile type. The data were further investigated using meta‐regression. Publication bias was also tested. Findings Stepwise profiling was shown to be statistically significantly effective in reducing intradialytic episodes. Results demonstrated that linear sodium profiling was not effective in reducing hypotensive events during dialysis. Discussion This review has shown that using stepwise profiling is more effective at reducing intra‐dialytic symptoms than other profiling methods. There was no evidence that linear profiling method was any more effective than conventional dialysis and in fact the results showed the reverse.     

The relationship between symptoms and blood pressure during maintenance hemodialysis

Intradialytic hypotension (IDH) is a detrimental complication of maintenance hemodialysis, but how it is defined and reported varies widely in the literature. European Best Practice Guideline and Kidney Disease Outcomes Quality Initiative guidelines require symptoms and a mitigating intervention to fulfill the diagnosis, but morbidity and mortality outcomes are largely based on blood pressure alone. Furthermore, little is known about the incidence of asymptomatic hypotension, which may be an important cause of hypoperfusion injury and impaired outcome. Seventy‐seven patients were studied over 456 dialysis sessions. Blood pressure was measured at 15‐minute intervals throughout the session and compared with post‐dialysis symptom questionnaire results using mixed modeling to adjust for repeated measures in the same patient. The frequency of asymptomatic hypotension was estimated by logistic regression using a variety of commonly cited blood pressure metrics that describe IDH. In 113 sessions (25%) where symptoms were recorded on the questionnaire, these appear not to have been reported to dialysis staff. When symptoms were reported (293 sessions [64%]), an intervention invariably followed. Dizziness and cramp were strongly associated with changes in systolic blood pressure (SBP), but not diastolic blood pressure. Nausea occurred more frequently in younger patients but was not associated with falls in blood pressure. Thresholds that maximized the probability of an intervention rather than a session remaining asymptomatic were SBP <100 mmHg or a 20% reduction in SBP from baseline. The probability of SBP falling to <100 mmHg in an asymptomatic session was 0.23. Symptoms are frequently not reported by patients who are hypotensive during hemodialysis, which leads to an underestimation of IDH if symptom‐based definitions are used. A revised definition of IDH excluding patient‐reported symptoms would be in line with literature reporting morbidity and mortality outcomes and include sessions in which potentially detrimental asymptomatic hypotension occurs.     

A psychobiocultural model of orthostatic panic among Cambodian refugees: Flashbacks, catastrophic cognitions, and reduced orthostatic blood-pressure response.

This paper investigates cognitive and physiological precursors of orthostatic panic (OP), that is, panic upon standing, which is a key complaint among traumatized Cambodian refugees. Prior research links OP to hypotension (lower blood pressure) and catastrophic cognitions. A clinical sample of 102 Cambodian refugees were assessed for posttraumatic stress disorder (PTSD), recent OP attacks, and anticipatory anxiety before engaging in an orthostatic challenge (OC) task during which they were monitored for blood pressure. After the task, they were assessed for OC-induced culture-related catastrophic cognitions, flashbacks, and panic attacks. We found that participants with recent OP (n = 60) had more PTSD, greater anticipatory anxiety before the OC, a larger drop in systolic blood pressure during the OC, more OC-induced catastrophic cognitions and flashbacks, and more severe OC-induced panic attack symptoms. Regression models showed that the severity of OC-induced panic symptoms was predicted by the magnitude of SBP drop and mediated by more severe catastrophic cognitions and flashbacks. Implications of the findings for cross-cultural psychopathology research and the treatment of both panic and PTSD in Cambodian refugees are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Adrenal insufficiency presenting as unexplained hypotension in nocturnal home hemodialysis

Adrenal insufficiency is a complication of chronic corticosteroid therapy. Unexplained hypotension may be a manifestation of an adrenal insufficient state in patients with a history of corticosteroid therapy on hemodialysis. We present a series of five cases of patients on nocturnal home hemodialysis with hypotension as the main manifestation of adrenal insufficiency. Unexplained hypotension in patients with a history of corticosteroid therapy should prompt the managing clinician to consider adrenal insufficiency as a possible cause.     

Cardiovascular dialysis instability and convective therapies

Acute hypotension is a frequent hemodialysis complication. Intratreatment vascular instability is a multifactorial process in which procedure-related and patient-related factors may influence the decrease in plasma volume and induce an impairment of cardiovascular regulatory mechanisms. Identification of the most susceptible patients and of the various risk factors may contribute to significantly improve cardiovascular stability during dialysis. In some high-risk patients, monitoring and biofeedback of the various hemodynamic variables, together with an extensive use of convection, can prevent the appearance of symptomatic hypotension and help in averting its onset.     

Oral intake during hemodialysis: Is there an association with intradialytic hypotension?

Oral intake (OI) of food and fluid has been associated with hypotension during hemodialysis (HD). Trials evaluating this relationship are small. The objective of this study was to quantify OI and to examine its association with hypotension during HD. This is a cross-sectional retrospective chart review study of 3 consecutive HD runs (dialysate iCa=1.25 mmol/L) in 126 stable HD patients (n=378). For each run, the calculation for OI=total ultrafiltration-(net weight loss+IV fluids given). Hypotension was defined as a systolic blood pressure of <100 mmHg at any point during the run. The mean age of the patients was 60.9 years, 38.2% were female, 30.2% had diabetes mellitus, and the majority were Caucasian. The mean (SD) OI was 0.27 (0.352) L/run, range -1.061 to 1.901 L/run, with a normal distribution. In bivariate analysis, there was no correlation of OI with systolic blood pressure, diastolic blood pressure, or mean blood pressure (BP), and the mean OI did not differ among runs with hypotension (n=78) compared with uncomplicated runs (p=0.93). Oral intake was not predictive of hypotension in a multiple logistic regression model controlling for vintage, age, sex, BP medications, coronary disease, dialysis day and shift, diabetes mellitus, s-Ca, Na and ultrafiltration profiles, and dialysis temperature, even when the analysis was restricted to runs where the patients reached the prescribed dry weight within 0.1 kg. The results of this study suggest that the mean OI during dialysis is just over 0.25 kg, with some patients consuming several kilograms. The clinical significance of OI is uncertain. We did not find an association between OI and hypotension. It is likely that this association was confounded by failure to achieve the prescribed dry weight in a proportion of patients with a high OI, as well as interventions implemented in response to hypotension in previous runs. For example, patients with previous episodes of low BP are advised to limit OI, are prescribed profiles, and so on. There may be other deleterious effects of high OI including hypertension and cardiac disease. The generalizability of the results of this largely Caucasian study population is a recognized limitation. Further prospective and blinded studies are needed to examine the association between OI and hypotension, the long-term clinical consequences of OI, and to define thresholds for recommended OI during dialysis.