UpToDate
Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate®

血液透析患者心力衰竭的治疗

Authors
Charles A Herzog, MD
William L Henrich, MD, MACP
Alfred K Cheung, MD
Section Editor
Jeffrey S Berns, MD
Deputy Editor
Alice M Sheridan, MD
Translators
陈光辉, 主任医师，副教授

概述

心室收缩或舒张功能障碍可导致临床上明显的心力衰竭(heart failure, HF)，甚至是在血液透析患者体重处于或接近于“干体重”时也是如此。心肌疾病和心血管药物也会降低血流动力学储备，这使患者在透析期间更容易出现低血压发作。

下面将要讨论的是具有慢性心力衰竭的血液透析患者的治疗方法。

治疗

主要的治疗障碍是普通人群中的心力衰竭处理的一般方法和推荐方法可能在心力衰竭的透析患者中不适用或者不一定是安全的。虽然针对收缩功能障碍患者的标准心力衰竭治疗很大程度上是基于在临床试验中已证实的针对病死率的效益，但对于透析人群，支持这种治疗安全性和疗效的证据有限。指导舒张性心力衰竭处理的证据有限，即便是在肾功能正常的患者中亦如此。 (参见“收缩功能障碍所致心力衰竭的治疗概述”和“射血分数保留型心力衰竭的治疗和预后”)

尽管如此，识别和纠正那些可能促进心力衰竭的可逆性因素和针对改善影响心肌功能不全的因素的干预可能改善透析人群的症状和结局。例如，阻塞性冠状动脉性疾病病变的血运重建、维持血红蛋白靶水平及推断的最佳干体重、确定最佳个体透析处方及给予恰当的药物治疗可能提高患者的舒适性并最终改善结局。

明确相关病况 — 许多可能的病况可能是心力衰竭发生的基础或者促进因素，应该寻找这些病况，且如有可能进行纠正。对于透析患者，这些病况可能包括如下：

               

Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: 2017-06 . | This topic last updated: 2017-05-10.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
References
Top
  1. K/DOQI Workgroup. K/DOQI clinical practice guidelines for cardiovascular disease in dialysis patients. Am J Kidney Dis 2005; 45:S1.
  2. Cice G, Ferrara L, D'Andrea A, et al. Carvedilol increases two-year survivalin dialysis patients with dilated cardiomyopathy: a prospective, placebo-controlled trial. J Am Coll Cardiol 2003; 41:1438.
  3. Zannad F, Kessler M, Lehert P, et al. Prevention of cardiovascular events in end-stage renal disease: results of a randomized trial of fosinopril and implications for future studies. Kidney Int 2006; 70:1318.
  4. Knoll GA, Sahgal A, Nair RC, et al. Renin-angiotensin system blockade and the risk of hyperkalemia in chronic hemodialysis patients. Am J Med 2002; 112:110.
  5. Suzuki H, Kanno Y, Sugahara S, et al. Effect of angiotensin receptor blockers on cardiovascular events in patients undergoing hemodialysis: an open-label randomized controlled trial. Am J Kidney Dis 2008; 52:501.
  6. Takahashi A, Takase H, Toriyama T, et al. Candesartan, an angiotensin II type-1 receptor blocker, reduces cardiovascular events in patients on chronic haemodialysis--a randomized study. Nephrol Dial Transplant 2006; 21:2507.
  7. Cice G, Di Benedetto A, D'Isa S, et al. Effects of telmisartan added to Angiotensin-converting enzyme inhibitors on mortality and morbidity in hemodialysis patients with chronic heart failure a double-blind, placebo-controlled trial. J Am Coll Cardiol 2010; 56:1701.
  8. Chan KE, Ikizler TA, Gamboa JL, et al. Combined angiotensin-converting enzyme inhibition and receptor blockade associate with increased risk of cardiovascular death in hemodialysis patients. Kidney Int 2011; 80:978.
  9. Chan KE, Lazarus JM, Hakim RM. Digoxin associates with mortality in ESRD. J Am Soc Nephrol 2010; 21:1550.
  10. Ritz E, Dikow R, Adamzcak M, Zeier M. Congestive heart failure due to systolic dysfunction: the Cinderella of cardiovascular management in dialysis patients. Semin Dial 2002; 15:135.
  11. Ventura HO, Mehra MR. Improvement of heart failure after renal transplantation: the complex maze of cardio-renal interaction. J Am Coll Cardiol 2005; 45:1061.
  12. Wali RK, Wang GS, Gottlieb SS, et al. Effect of kidney transplantation on left ventricular systolic dysfunction and congestive heart failure in patients with end-stage renal disease. J Am Coll Cardiol 2005; 45:1051.
  13. Singh SM, Wang X, Austin PC, et al. Prophylactic defibrillators in patients with severe chronic kidney disease. JAMA Intern Med 2014; 174:995.