研究背景：腎病末期接受血液透析患者逐年增加，隨著透析技術的改進，患者的生命亦隨之延長。同時腎病末期的併發症相對增多，最重要的死亡及罹病原因為心血管疾病，動脈硬化變成心血管疾病的一個重要危險因子。過去30年接受血液透析患者的動脈脈波速率(PWV)與發生心律不整之間的關聯已被廣泛研究，而主動脈脈波速率(aortic PWV)與接受血液透析患者心律不整的發生是主要被討論的主題。但是因其為侵入性技術且成本偏高的限制，使得非侵襲性且低成本的上臂足踝脈波速率(baPWV)，成為接受血液透析患者發生心律不整的一個可能預測因子，但是未曾直接探討過彼此之間的關聯。
目的：確認上臂足踝脈波速率(baPWV)成為腎病末期接受血液透析患者發生心律不整的預測因子。
方法與材料：自民國93年11月起至94年12月，樣本來自三所獨立血液透析中心，共134位接受血液透析患者。納入準則須符合近6個月病況穩定，未服用抗心律不整藥物，每週血液透析3次，毎次透析3至4小時，且使用同一種透析濾芯及重碳酸緩衝液透析患者。依據病歷記載登錄每位受測者基本資料，包含年齡、性別及相關疾病(糖尿病、慢性腎病、高血脂症、高血壓、冠心病)，並且記錄每位受測者血液透析年資。每一位受測者，於裝設24小時Holter攜帶式心電圖記錄器前兩週內，施行心臟超音波檢查，記錄是否有左心室肥厚現象。於血液透析前一日以Colin VP-1000儀器( Colin Co.Ltd, Komaki, Japan )測量上臂足踝脈波速率( baPWV )值。接受血液透析前至少8至12小時裝設24小時Holter攜帶式心電圖紀錄器，至總時間24小時，將記錄磁片經電腦分析後，依據Lown B and Wolf M 心室心律不整定義，確認心室心律不整的等級( Lown’s Class 0, 1, 2, 3, 4 or 5 )，並定義Lown’s Class 3以上(含)者為發生心室心律不整之患者。受測者於透析開始前抽血測鉀、鎂、鈣、磷、尿素氮及肌酸酐等生化值。描述性統計藉由平均值、標準差及百分比呈現各自變項的中央與離散程度。推論性統計首先採用t檢定，分析連續變項與心室心律不整發生之間的相關性。再利用羅吉斯回歸分析( Logistic Regression Analysis )與逐步羅吉斯回歸分析( Stepwise Logistic Regression Analysis )，於baPWV不設虛擬變項及baPWV設虛擬變項(R1，R2，R3)，控制住性別、年齡、透析年資、鎂離子、鉀離子、鈣離子、磷離子、左心室肥厚、糖尿病、慢性腎病、高血脂症、高血壓及冠心病等13項干擾因素後分別進行羅吉斯回歸分析( Logistic Regression Analysis )與逐步羅吉斯回歸分析( Stepwise Logistic Regression Analysis )。試著尋找baPWV與心室心律不整發生之間的最佳預測模型，統計學上定義P<0.05有顯著意義。
結果：經控制住干擾因子後羅吉斯回歸分析顯示上臂足踝脈波速率(baPWV)與心室心律不整之間有顯著相關依據反向羅吉斯回歸分析試著找出一個最佳預測模型Y = (-1.8326) + 20.333R2 + 3.7297R3 。
結論：當腎病末期接受血液透析患者的上臂足踝脈波速率(baPWV)大於1800 cm/sec，同時合併高血壓及冠心病之危險因子，非侵襲性且低成本的上臂足踝脈波速率(baPWV)，可能是腎病末期接受血液透析患者發生心室心律不整的一個最佳預測因子。
Background: The cases of end-stage renal disease receiving hemodialysis increased year after year. Through the improvement of hemodialytic quality, patient’s life prolonged. But at the same time, complications of these patients became exacerbation. The most important cause of mortality and mobidity of end-stage renal disease was cardiovascular disease. Vascular stiffness became one of the important risk factors of cardiovascular disease. Since the correlation of pulse wave velocity(PWV) and ventricular arrhythmias on the patients under hemodialysis had been evaluated during past three decades. Aortic PWV was the most discussed issue with the presence of ventricular arrhythmia on patients under hemodialysis. But its limitation of invasive technique and high cost made the noninvasive and low cost brachioankle pulse wave velocity(baPWV) became a new possible predictor of ventricular arrhythmias on patient under hemodialysis. But no study had been done for the correlation of baPWV and ventricular arrhythmias directively on the patients under hemodialysis.
Purpose: To define the value of baPWV as a predictor for ventricular arrhythmia on end-stage renal disease patient under hemodialysis.
Method and Material: Total 72 cases of end-stage renal disease under hemodialysis were collected from three indendent hemodialytic centers from December 2004 to November 2005. The included criterias were stable condition during past six months, no anti-arrhythmic agents taking, with regular hemodialysis three times a week, and 3 to 4 hours interval of each hemodialytic duration. Each case received echocardiographic evaluation the presence of left ventricular hypertrophy two weeks before 24 hour’s Holter ECG monitor. One day before ECG monitoring, baPWV was detected and recorded. The 24 hour’s Holter ECG monitor was applied at least 8 to 12 hours before hemodialysis. Total 24 hours’ recording period was completed. Then the ECG monitor was removed. The blood sample was taken for biochemistry study before hemodialysis began. T-test, Logistic regression analysis, and stepwise Logistic regression analysis were used to define the predictive value of baPWV for the presence of ventricular arrhythmia of end-stage renal disease under hemodialysis.
Results: Under controlling of those confounding factors the Logistic Regression Analysis found that baPWV correlated with ventricular arrhythmia significantly. We tried to define a predictive model Y = (-1.8326) + 20.333R2 + 3.7297R3 according to the result of backward Logistic Regression Analysis.
Conclusion: When the end-stage renal disease patients under hemodialysis with increased baPWV > 1800 cm/sec combined with risk factors of hypertension and coronary artery disease. The baPWV might be a predictor of ventricular arrhythmias on patients under hemodialysis.
