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혈액투석중 발생하는 저혈압과 순환 혈액량 변화 및 혈장 Mitric Oxide의 변화
김성호,김성록,권태환,김석재,김용림,조동규 대한신장학회 2000 Kidney Research and Clinical Practice Vol.19 No.5
Background: Dialysis-induced hypotension is one of the most frequent acute complications during hemodialysis. It has been suggested that the inflammatory cytokines interlukin-1 and tumor necrosis factors mediate this hypotension through production of vasodilating nitric oxide. The vasodilating actions of these cytokines are also mediated by the nitric oxide in the vascular smooth muscle cells. It is also hypothesized that the blood volume changes independent of nitric oxide play an important role in intradialytic hypotension so that present study was undertaken to determine the relationship of blood volume and nitric oxide level to the intradialytic hypotensive episodes. Methods: The changes of the blood volume and the plasma level of nitrite and nitrate, the metabolic products of nitric oxide, were measured. Patients who did(hypotensive group, n=6) and did not have hypotensive episodes(normotensive group, n=13) during hemodialysis sessions were included. Hypotensive episodes during dialysis were defined as drop of systolic blood pressure $lt;90mmHg or mean arterial pressure $lt;75mmHg. The blood volume change was measured by using continuous monitor(Crit-Line: In-Line Diagnostics, UT, USA) and the plasma nitrite and nitrate level were measured using a nitrate/nitrite assay kit(Cayman Chemical Company, MI, USA). Results: The maximal mean arterial pressure change was 51.8±11.9mmHg in the hypotensive group and 5.0±11.7mmHg in the normotensive group(p$lt;0.05). The maximal blood volume change was 18.9±4.0% in the hypotensive group and 9.2±3.2% in the normotensive group(p$lt;0.05). In the hypotensive group and the normotensive group, the nitrite and nitrate levels at the beginning of hemodialysis, 2 hours after the initiation of hemodialysis and at the end of hemodialysis were 480.6±287.1μmoL/L vs. 600.6±335.5μmoL/L, 268.2±129.7μmoL/L vs. 479.2±470.6μmoL/L, 204.9±58.2μmoL/L vs. 268.7±137.5μmoL/L respectively and there were no significant differences between the two groups at each measurement time(p$gt;0.05). It wath groups that the serum nitrite/nitrate level dropped significantly at the end of dialysis(p$lt;0.05). The volume of ultrafiltration, ultrafiltration rate, serum calcium levels, hematocrit, serum albumin levels and the amount of hepariri used were not different between the two groups. Conclusion: Although it has been proposed that dialysis-induced hypotension is mediated by production of cytokine-induced nitric oxide in vascular smooth muscle cells, the nitrite/ nitrate level in plasma decreased in both groups of the patients who did or did not have hypotensive episodes during hemodialysis in present study. However, the blood volume was markedly decreased in patients who had hypotensive episodes. This suggests that the blood change rather than the plasma nitric oxide level during hemodialysis contributes to dialysisinduced hypotension.