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Том 21 №1 2019 год - Нефрология и диализ

Роль артериовенозной фистулы в формировании легочной гипертензии у пациентов на заместительной почечной терапии. Обзор литературы

Исхаков Р.Т. Зелтынь-Абрамов Е.М. Потешкина Н.Г. Белавина Н.И.

DOI: 10.28996/2618-9801-2019-1-19-31

Аннотация: Легочная гипертензия (ЛГ) представляет собой сложный патофизиологический и клинический феномен, характеризующийся прогрессирующим повышением давления в легочной артерии (ДЛА). Рост ДЛА может привести к необратимым структурным изменениям легочного сосудистого русла. Клиническим проявлением патоморфологических изменений является формирование тяжелой, часто необратимой, правожелудочковой недостаточности. ЛГ широко распространена среди пациентов с продвинутыми стадиями хронической болезни почек (ХБП), в том числе, получающих заместительную почечную терапию (ЗПТ), являясь независимым предиктором летальности и сердечно-сосудистых осложнений в данной популяции. Патогенетические механизмы формирования ЛГ у пациентов на ЗПТ многообразны и остаются предметом дискуссии. В ряде случаев в качестве причины формирования ЛГ выступают заболевания, коморбидные диализ-потребной ХБП или непосредственно приведшие к ее развитию. Однако в настоящее время внимание экспертов сосредоточено на изучении нейрогуморальных и гемодинамических паттернов развития ЛГ, связанных как с особенностями патоморфоза ХБП, так и с воздействием функционирующей артериовенозной фистулы (АВФ) на центральную гемодинамику. Уточнение гемодинамических аспектов формирования ЛГ у пациентов с АВФ и выработка доказательных лечебных и обсервационных стратегий невозможны без дальнейшего определения влияния АВФ per se на сердечно-сосудистую систему конкретного пациента. Диагностический подход к оценке вероятных клинических сценариев включает в себя этапное эхо-кардиографическое наблюдение, катетеризацию правых отделов сердца, пробу временной окклюзии АВФ. Все диагностические маневры следует проводить с учетом закономерных колебаний волемического статуса пациента, находящегося на программном гемодиализе. Корректная методологическая оценка вклада АВФ в формирование ЛГ позволит сформулировать конкретные лечебные стратегии в диапазоне от реконструкции сосудистого доступа до смены вида ЗПТ.

Для цитирования: Исхаков Р.Т., Зелтынь-Абрамов Е.М., Потешкина Н.Г., Белавина Н.И. Роль артериовенозной фистулы в формировании легочной гипертензии у пациентов на заместительной почечной терапии. Обзор литературы. Нефрология и диализ. 2019. 21(1):19-31. doi: 10.28996/2618-9801-2019-1-19-31

Весь текст

Ключевые слова: легочная гипертензия, артериовенозная фистула, сердечная недостаточность с высоким сердечным выбросом, заместительная почечная терапия

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