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말기신장질환의 혈역학적 연구

Other Titles
 Hemodynamic study in end-stage renal disease 
Issue Date
1979
Description
의학과/박사
Abstract
[한글] 장기혈액투석이 보편화되면서 말기신장질환환자의 치료에 획기적인 전기를 맞게 되어 많은 환자들이 수명의 연장은 물론 생산적인 직업활동에 종사할 수 있게 되었다. 그러나 장기간 혈액투석을 받는 동안 여러 가지 합병증이 야기되며 그중에서도 심근경색증, 울혈 성심부전같은 심혈관계합병증은 으뜸가는 사망원인이 되고 있다. 우리나라에서도 최근 장 기혈액투석이 널리 시행됨에 따라 이에 대한 합병증이 문제시되고 있으며, 임상적으로는 울혈성심부전이 가장 흔한 합병증의 하나이다. 따라서 말기신장질환에 있어서의 혈역학적 변화에 대한 지식은 장기혈액투석시 초래되는 심혈관계합병증을 예방하고 치료하는데 매 우 중요하다. 대상환자는 16예의 말기신장질환환자들로서 전 예에서 좌우심도자술을 시행하였다. 12 예는 장기혈액투석을 시작하기 전에 검사를 시행하였는데, 이들중 9예는 장기혈액투석을 위한 arteriovenous fistula (A-V fistula)나 shunt도 없었고, 3예는 A-V fistula를 만든 다음날 좌우심도자술을 시행하였다. 나머지 4예는 2-22개월간 장기 혈액투석을 받아 오 던 중 고질적 심부전이 재발하여 혈역학적검사를 시행한 환자들이었다. 좌우심도자술을 시행하여 폐동맥압, 우심방압, 좌심실압, 대동맥압을 측정하였고 고질 적인 심부전을 일으켰던 장기혈액투석환자중 2예에서는 A-V fistula를 압박하여 혈액의 전류를 차단한 후 재차 혈역학적인 기록을 하였다. 또한 혈관확장제가 심장기능에 미치는 영향을 관찰하기 위하여 7예에서 nitroglycerin 0.6mg을 설하투여한 후 혈역학적변화를 관찰하였다. Cardiac output Fick's principle에 의하여 구하였고, LVdp/dt, pressure rate index(P RI),cardiac index(CI), stroke index(SI), left ventricular work index(LVWI), stoke w ork index(SWI), systemic vascular resistance(SVR)등을 산출하였다. 말기신장질환의 혈역학적변화를 관찰한 결과 다음과같은 결론을 얻을 수 있었다. 1. 장기혈액투석을 받은 일이 없는 말기신장질환환자군(12예)에서 cardiac index, stro ke index, left ventricular work index, stroke work index등이 증가하고 동맥압이 증가 하였지만, 전신혈관저항은 증가하지 않았고 LVdp/dt와 좌심실말기이완기압은 정상범위였 다. 즉 이들 환자에서는 동맥압과 심박출량이 증가하여 좌심실의 작업량이 증가하여 있었 지만, 심근수축력과 좌심실말기이완기압이 정상임을 볼 때 말기신장잘환에 있어서의 심실 기능은 정상으로 생각되었다. 2. 장기혈액투석을 받던 중 울혈성심부전을 일으켰던 4예에서도 cardiac index, stroke index, left ventricular work index, stroke work index,동맥압등이 현저히 증가하여 있었으며 전신혈관저항은 전자의 군보다 감소되어있었다. LVdp/dt는 정상범위였으며, 좌 심실말기이완기압과 pressure rate index는 전자의 군보다 현저히 증가되어있었다. 따라 서 이들에 있어서 좌심실말기이완기압이 상승한 것은 전신혈관 저항이 감소되었음에도 불 구하고 심박출량이 과도히 증가하여 좌심실작업량이 증가된 결과 초래된 high-output fai lure에 의한 것이 주된 원인으로 생각되었고, 심실비대의 결과로 초래된 심실의 diastoli c compliance의 감소가 심부전을 촉진시켰을 또 하나의 가능성으로 생각되었다. 3. 장기혈액투석으로 high-output failure가 초래되었던 4예중 3예는 검사후 A-V fistu la를 결찰하고 새로이 external A-V shunt를 만들어 혈액투석을 시행함으로서 심부전이 치료되었고, 1예는 혈액투석회수를 증가시키고 수분섭취를 엄격히 제한함으로서 역시 심 부전이 치료되었다. 4. 혈관확장제인 nitroglycerin을 투여함으로써 cardic index는 nitroglycerin투여전후 에 변화가 없었으나, 대동맥압, 전신혈관저항, 좌심실말기이완기압, 폐동맥, stroke work index등이 감소되었다. 즉 nitroglycerin은 심박출량에는 변화가 없이 심장의 전부하와 후부하를 모두 감소시켜서 심장의 작업량을 감소시켜주었다. 따라서 nitroglycerin은 말 기신장질환에서도 울혈성심부전의 치료에 많은 도움이 될 것으로 생각된다.
[영문] Cardiac failure is common in patients with end-stage renal disease, but its definite mechanism is still uncertain. Anemia, fluid imbalance, persistent hypertension and cardiac disorders pose major problem in many patients. Though chronic hemodialysis therapy has clearly altered the course of the disease there are several shortcomings to our present mode of renal replacement therapy. The leading cause of death in these patients has been cardiovascular complications, in particular, congestive heart failure. The stresses sustained by the myocardium in the hemodialysis patients are formidable. These include severe anemia, arteroivenous fistula, episodic extracorporeal circulation and hypertension in most instances. The work demands of the heart, thus appearing to be excessive, might thereby be a contributing factor to the mortality now attributable to failure of this organ. Consequently, this investigation undertook the hemodynamic study in patients with end-stage renal disease. Materials and Methods Sixteen patients, 14 men and 2 women aged 23 to 64 (mean 36) years were examined. The study was done on 12 patients before maintenance hemodialysis and 4 patients with congestive heart failure on hemodialysis. Although most of the patients were hypertensive, none had clinical and electrocardiographic evidence of myocardial disease or myocardial infarction. Under local anesthesia, right and left heart vatherterization was done. Control hemodynamic measurements were obtained after 3-min successive occlusion of the arteriovenous shunt in 2 patients on chronic hemodialysis. After completion of control measurements, 0.6mg nitroglycerin was administered sublingually in 7 patients. And hemodynamic measurements were done every 2 minutes for 20 minutes. Measurements of pulmonary artery, right atrial, left ventricular and aortic pressures were obtained with Statham P^^23 ID strain-gauge transducers. The first derivative of the left ventricular pressure curve(LV에/dt) was directly measured on the LV pressure curve. Cardiac output determinations were made by Fick's principle. Pressure rate index(PRI), cardiac index(CI), stroke work index(SWI), left ventriclal work index(LVWI), and systemic vascular resistance(SVR) were calculated. Results and Conclusion 1. Twelve patients with end-stage renal disease had high CI, SI, LVWI. SWI and aortic pressure. The LV에/dt and left ventricular end-diastolic pressure(LVEDP) were normal. The SVR was not elevated. These hemodynamic data suggested that the left ventricular function is adequate despite the abnormal loading condition. 2. In 4 patients with congestive heart failure on chronic hemodialysis the CI, SI, LVWI. SWI and aortic pressure were markedly elevated. The LVdp/dt was normal. The LVEDP was markedly elevated. The PRI was also elevated. High-output cardiac failure was suggested. 3. In 3 of the 4 patients with congestive heart failure on hemodialysis the forearm fistulas were ligated and external arteriovenous shunts were made after hemodynamic study. Surgical correction of high flow fistula resulted in nortable improvement of cardiac failure. The remaining one patient was stable on rigid control of hypertension and chronic fluid overload. 4. In 7 patients receiving nitroglycerin LVEDP, aortic pressure, SVR, pulmonary artery pressure and SWI were markedly reduced. But the cardiac index was unchanged. The possible sequence of pathologic event leading to myocardial failure in end-stage renal disease begins with an increase in cardiac work(stoke work index), the resulting effect of several factors including chronic pressure and volume overload states. Elevations in cardiac work promote myocardial hypertrophy resulting in increased myocardial oxygen requirement which in turn may not be met because of the reduced erythrocyte mass. But the left ventricular function is adequate the abnormal loading conditions. However left ventricular end-diastolic pressure is primarily influenced by volume loads and by ventricular distensibility modification. Subcutaneous arteriovenous fistula may develop high-output cardiac failure in patients on chronic hemodialysis. The A-V shunting of blood is a contributary cause for further elevation of cardiac output in dialysis patients with congestive heart failure. The hemodynamic action of vasodilator drug (nitroglycerin) is marked reduction in left ventricular end-diastolic pressure (preload) and aortic pressure (afterload) without pronounced effect on cardiac output. Therefore this agent can be used effectively in end-stage renal disease with congestive heart failure with a beneficial hemodynamic response.
URI
http://ir.ymlib.yonsei.ac.kr/handle/22282913/115343
Appears in Collections:
2. 학위논문 > 1. College of Medicine > 박사
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