ESRD肺动脉高压.ppt
ESRD 肺动脉高压肺动脉高压的定义肺动脉高压的定义 Systolic pulmonary arterial pressure（PAP）PAP=cardiac output x PVR 65 重度 Seminars in Dialysis,2006 353-35725mmHg Mahans equation:right ventricular outflow tract flow acceleration time MPAP(mmHg)=79-0.45X acceleration time(ms)Cardiac output(ml/min)=stroke volume(ml)Xheart rate(min-1)stroke volume from end-diastolic volume Simpsons methodmodified Bernoulli equation:PAP=tricuspid systolic jet(TR)+10-15 mm Hg(estimated right atrial pressure:15 mm Hg in dilated right atrium 10 mmHg in normal or slightly enlarged right atrium PHT:systolic PAP 35 mmHg.Systolic PAP=4xTR+RAP TR:tricuspid regurgitation(m/sec)RAP:right artial pressure60 重度 cardiovasc Intervent Radiol 2005,28:17-22 40%血透患者：447mmHg(37-65)ESRD PH发生率与可能机制1.left heart failure 2.chronic hypoxic lung diseases.3.Collagen vascular diseases,5.portal hypertension4.chronic recurrent thromboembolism6.human immunodeficiency virus(HIV)infection,7.hematologic conditions 8.Secondary drugs and toxins我院血透中心不完全统计HD 27/59(45.8%)53.015.3mmHgPD 15/51(29.4%)40.79.7mmHgTable 1.Systolic Pulmonary arterial pressure(PAP)in hemodialysis patients Saudi J Kidney Dis Transpl.2008 Mar-Apr;19(2):189-93 PH相关因素 贫血、低蛋白血症贫血、低蛋白血症 PH者心输出量更高者心输出量更高 内皮功能（内皮功能（NOS-ET）AV内瘘患者、移植内瘘患者、移植 内瘘血流量与通路取栓术内瘘血流量与通路取栓术 其它：年龄？其它：年龄？转移性钙化转移性钙化PH与低蛋白血症和贫血相关与低蛋白血症和贫血相关 control PH Hb 11.1 1.86 9.8 1.97 p=0.012 Alb 3.75 0.44 3.38 0.32 p=0.02Saudi J Kidney Dis Transpl.2008 Mar-Apr;19(2):189-93 Saudi J Kidney Dis Transpl.2008 Mar-Apr;19(2):189-93 PHA与心输出量和射血分数相关Curr Opin Nephrol Hypertens 15:353360.2006PH与心输出量关系 平均PH 与心脏射血分数相关 r=0.453,p=0.014Int Urol Nephrol,2007,JulyNO/内皮系统与肺动脉压关系收缩血管物质收缩血管物质ET-1所有透析患者，透后所有透析患者，透后高于透前，高于正常高于透前，高于正常对照对照HD/PH与与HD/NPH没没有差异有差异透前后没有差异透前后没有差异Curr Opin Nephrol Hypertens 15:353360.2006扩血管物质扩血管物质NO2+NO3:所有透析患者透后所有透析患者透后升高升高HD/PHA透前后均低透前后均低于非于非PHA患者患者Curr Opin Nephrol Hypertens 15:353360.2006移植前后、A-V瘘闭前后PAP和心输出量的差别 ESRD取栓取栓 非非CKD ESRD未取栓未取栓Number 88 100 117F/Males 47:41 54:46 59:58age 56.5 60 54.7PH 46(52%)26(26%)49(42%)Mild 23(26%)1(1%)29(25%)Moderate 9(10%)5(5%)1(1%)Severe 14(16%)7(7%)5(4%)HD:PD 88:0(100%)0 30:87(26%)通路取栓术与PH关系Cardiovasc Intervent Radiol(2005)28:1722Cardiovasc Intervent Radiol(2005)28:1722PHA与透析一般情况无关 年龄、性别、透析时间年龄、性别、透析时间 血压血压 吸烟吸烟 心脏结构、瓣膜钙化、心输出量心脏结构、瓣膜钙化、心输出量 钙、磷、钙、磷、AKP、PTH 血脂血脂Cardiovasc Intervent Radiol(2005)28:1722Hemodialysis International 2006;10:356359Distribution of systolic pulmonary artery pressureaccording to degree of technetium-99 methylene diphosphonatepulmonary uptake（99mTCMDP肺摄取肺摄取肺钙化）肺钙化）Curr Opin Nephrol Hypertens 15:353360.2006CASE REVIEW 1.新发肺动脉高压 1年 2.高血压、贫血、AV瘘 3.射血分数、容量负荷：变化？4.肺基础：血管张力？低氧？肺栓塞？AV分流
