血液透析患者の自律神経機能の検討　起立性低血圧の成因とその看護

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  • Evaluation of autonomic functions in regular hemodialysis patients: Pathogenesis and management of orthostatic hypotension.
  • Pathogenesis and management of orthostatic hypotension
  • 起立性低血圧の成因とその看護

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We evaluated autonomic functions by means of cold pressor, norepinephrine and atropine tests in twelve patients undergoing regular hemodialysis (six patients were diabetic). Five of seven patients (including five diabetic patients) having orthostatic hypotension showed abnormal responses to the cold pressor test. After norepinephrine injection, these seven patients showed hyper-reactive responses, similar to the responses of patients with denervation super-sensitivity. These results indicate that disturbance of postganglionic sympathetic neurons could be involved in the pathogenesis of orthostatic hypotension in patients on regular hemodialysis. When atropine, a muscarinic acetylcholine blocker, was injected, four patients with orthostatic hypotension presented sympathetic signs, although an increase in heart rate was not observed. These observations indicate that a parasympathetic fiber disorder could also contribute to the pathogenesis of the orthostatic hypotension. Based on these findings, in order to prevent orthostatic hypotension, we tried to educate the patients and instructed them as to appropriate daily behavior. In addition, we monitored blood pressure as well as EGG during hemodialysis as part of the management of patients with orthostatic hypotension, because the heart rate did not increase even when hypovolemic shock ensued in these patients. Four patients exhibiting orthostatic hypotension and postganglionic sympathetic nerve disorders were treated with midodrine, a specific α1 receptor stimulator, in order to prevent orthostatic hypotension after hemodialysis treatment. These maneuvers were useful for the management of the orthostatic hypotension.

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