维持性血液透析患者临床特征及透析效果横断面调查
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摘要
目的探讨维持性血液透析(MHD)患者的临床特征及透析指标的达标情况。方法对2016年11月开始于肾内科行MHD治疗的终末期肾病患者进行横断面研究。观察指标包括一般情况、透析前C-反应蛋白(CRP)、血红蛋白(Hb)、血钙、血磷、甲状旁腺激素(PTH)、白蛋白(Alb)、尿素氮(BUN)、血肌酐(Scr)等;并以年龄、糖尿病分层进行组间临床特征及透析指标比较。结果 (1)共纳入67例患者,60岁以上患者35例(52.2%),透析时长(13.3±4.6)月,主要病因为慢性肾小球肾炎44例(65.7%),其次为糖尿病肾病10例(14.9%)。(2)CRP<5 mg/L的患者41例,达标率为61.2%;110 g/L≤Hb<130 g/L的患者30例,达标率为44.8%;2.1 mmol/L≤血钙≤2.37 mmol/L的患者39例,达标率为58.2%;1.13 mmol/L≤血磷≤1.78 mmol/L的患者33例,达标率为49.3%;钙磷乘积<55 mg/dl的患者45例,达标率为67.2%;150 ng/L≤PTH≤300 ng/L的患者27例,达标率为40.3%;Alb>35 g/L的患者63例,达标率为94.0%。(3)老年患者Alb、血钙、血磷、PTH、BUN及Scr水平明显低于非老年患者(P<0.05,P<0.01)。(4)糖尿病组与非糖尿病组患者Scr水平均增高,但非糖尿病肾病患者Scr水平明显高于糖尿病肾病患者(Z=2.173,P=0.03)。其余透析指标比较无统计学差异(P均>0.05)。结论 MHD对终末期肾病患者具有较好效果,"微炎症状态"及肾性贫血得到较好控制;营养状况良好;血钙、血磷、PTH达标率高;对糖尿病肾病患者更加符合透析要求;对老年患者,应合理选择个体化的治疗方案,尽可能改善老年患者的长期预后。
Objective To investigate the clinical characteristics and the attainment of dialysis indexes in maintenance hemodialysis(MHD) patients with end-stage renal disease.Methods A cross-sectional investigation was performed on MHD patients treated in the nephrology department from November 2016.General condition,c-reactive protein(CRP),hemoglobin(HB),serum calcium(Ca),serum phosphorus(P),parathyroid hormone(PTH),albumin(Alb),blood urea nitrogen(BUN) and serum creatinine(Scr) were observed;the clinical characteristics and dialysis indicators were compared among groups based on age and diabetes stratification.Results(1) Out of 67 patients involved,35 patients(52.2%) were over 60 years old.The average duration of dialysis was(13.3±4.6) months.The main cause of end-stage renal disease was chronic glomerulonephritis(65.7%),followed by diabetic nephropathy(14.9%).(2)The attainment rates of CRP(<5 mg/L),HB(110 g/L≤HB<130 g/L),Ca(2.1 mmol/L≤Ca≤2.37 mmol/L),P(1.13 mmol/L≤P≤1.78 mmol/L),calcium-phosphorus product(<55 mg/dl),PTH(150 ng/L≤PTH≤300 ng/L),Alb(>35 g/L) were respectively 61.2%(41 patients),44.8%(30 patients),58.2%(39 patients),49.3%(33 patients),67.2%(45 patients),94.0%(63 patients).(3) The levels of Alb,Ca,P,PTH,BUN and Scr in elderly patients were significantly lower than those in non-elderly patients(P<0.05,P<0.01).(4) Scr level increased in both diabetic and non-diabetic groups,but it was significantly higher in non-diabetic nephropathy patients than that in diabetic nephropathy patients(Z=2.173,P=0.03).There were no significant differences in other dialysis indicators(all P>0.05).Conclusions MHD has a good effect on patients with end-stage renal disease and well controls "micro-inflammatory state" and renal anemia.The nutritional statu of patients is good with higher standard rates of calcium,phosphorus and PTH.The patients with diabetic nephropathy are more in line with the requirements of dialysis.The individual treatment should be rationally selected to improve the long-term prognosis of elderly patients as far as possible.
Objective To investigate the clinical characteristics and the attainment of dialysis indexes in maintenance hemodialysis(MHD) patients with end-stage renal disease.Methods A cross-sectional investigation was performed on MHD patients treated in the nephrology department from November 2016.General condition,c-reactive protein(CRP),hemoglobin(HB),serum calcium(Ca),serum phosphorus(P),parathyroid hormone(PTH),albumin(Alb),blood urea nitrogen(BUN) and serum creatinine(Scr) were observed;the clinical characteristics and dialysis indicators were compared among groups based on age and diabetes stratification.Results(1) Out of 67 patients involved,35 patients(52.2%) were over 60 years old.The average duration of dialysis was(13.3±4.6) months.The main cause of end-stage renal disease was chronic glomerulonephritis(65.7%),followed by diabetic nephropathy(14.9%).(2)The attainment rates of CRP(<5 mg/L),HB(110 g/L≤HB<130 g/L),Ca(2.1 mmol/L≤Ca≤2.37 mmol/L),P(1.13 mmol/L≤P≤1.78 mmol/L),calcium-phosphorus product(<55 mg/dl),PTH(150 ng/L≤PTH≤300 ng/L),Alb(>35 g/L) were respectively 61.2%(41 patients),44.8%(30 patients),58.2%(39 patients),49.3%(33 patients),67.2%(45 patients),94.0%(63 patients).(3) The levels of Alb,Ca,P,PTH,BUN and Scr in elderly patients were significantly lower than those in non-elderly patients(P<0.05,P<0.01).(4) Scr level increased in both diabetic and non-diabetic groups,but it was significantly higher in non-diabetic nephropathy patients than that in diabetic nephropathy patients(Z=2.173,P=0.03).There were no significant differences in other dialysis indicators(all P>0.05).Conclusions MHD has a good effect on patients with end-stage renal disease and well controls "micro-inflammatory state" and renal anemia.The nutritional statu of patients is good with higher standard rates of calcium,phosphorus and PTH.The patients with diabetic nephropathy are more in line with the requirements of dialysis.The individual treatment should be rationally selected to improve the long-term prognosis of elderly patients as far as possible.
引文
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[17] Bellasi A,Mandreoli M,Baldrati L,et al.Chronic kidney disease progression and outcome according to serum phosphorus in mild-to-moderate kidney dysfunction[J].Clin J Am Soc Nephrol,2011,6(4):883-891.
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[20] 刘丽茹,何敏华.维持性血液透析患者钙磷代谢及甲状旁腺素水平横断面调查[J].临床肾脏病杂志,2018,18(1):25-29.
[21] Combe C,Chauveau P,Laville M,et al.Influence of nutritional factors and hemodialysis adequacy on the survival of 1,610 French patients[J].Am J Kidney Dis,2001,37(1 Suppl 2):S81-S88.
[22] 宋佳,焦军东.评估血液透析患者营养状况的方法[J].中国中西医结合肾病杂志,2018,19(1):87-89.
[23] Harhay MN,Harhay MO,Coto-Yglesias F,et al.Altitude and regional gradients in chronic kidney disease prevalence in Costa Rica:data from the Costa Rican longevity and healthy aging study[J].Trop Med Int Health,2016,21(1):41-51.
[24] Otero González A,Iglesias Forneiro A,Camba Caride MJ,et al.Survival for haemodialysis vs.peritoneal dialysis and technique transference.Experience in Ourense,Spain,from 1976 to 2012[J].Nefrologia,2015,35(6):562-566.
[25] 朱永坚.老年人终末期肾病血液净化治疗的进展[J].临床与病理杂志,2017,37(11):2494-2499.
[26] 皇甫珍慧,胡晓舟,王少亭,等.老年维持性血液透析患者钙磷代谢紊乱情况及影响因素[J].中国老年学杂志,2015,35(24):7146-7148.
[27] Masakane I,Nakai S,Ogata S,et al.An overview of regular dialysis treatment in japan (as of 31 december 2013)[J].Ther Apher Dial,2015,19(6):540-574.
[28] Agarwal SK,Dash SC.Spectrum of renal diseases in Indian adults[J].J Assoc Physicians India,2000,48(6):594-600.
[29] Batista PB,Lopes AA,Costa FA.Association between attributed cause of end-stage renal disease and risk of death in Brazilian patients receiving renal replacement therapy[J].Ren Fail,2005,27(6):651-656.
[30] 吴小群.糖尿病肾病与非糖尿病肾病患者维持性血液透析疗效比较[J].医学综述,2012,18(14):2301-2302.
[2] Kim YW,Park S.Confronting practical problems for initiation of on-line hemodiafiltration therapy[J].Electrolyte Blood Press,2016,14(1):1-4.
[3] 乔勤,顾波.我国与全球终末期肾脏病的流行现状[J].中国血液净化,2014,13(10):729-732.
[4] 中国医院协会血液净化中心管理分会血液透析登记组.我国面临快速增长的终末期肾病治疗负担[J].中国血液净化,2010,9(1):47-49.
[5] 申万琴.血必净注射液对慢性肾衰患者微炎症状态影响分析[J].中国现代药物应用,2016,10(2):144-145.
[6] 许琴,赵烨,徐煜,等.血液透析、腹膜透析2种透析方式对慢性肾衰竭尿毒症患者微炎症状态的影响[J].现代中西医结合杂志,2017,26(2):155-156.
[7] McIntyre CW.Effects of hemodialysis on cardiac function[J].Kidney Int,2009,76(4):371-375.
[8] Yudkin JS,Kumari M,Humphries SE,et al.Inflammation,obesity,stress and coronary heart disease:is interleukin-6 the link?[J].Atherosclerosis,2000,148(2):209-214.
[9] 张俊.维持性血液透析患者微炎症状态与营养不良的关系[J].医学综述,2014,20(7):1180-1182.
[10] Garrido P,Ribeiro S,Fernandes J,et al.Iron-hepcidin dysmetabolism,anemia and renal hypoxia,inflammation and fibrosis in the remnant kidney rat model[J].PLoS One,2015,10(4):e0124048.
[11] He J,Shlipak M,Anderson A,et al.Risk factors for heart failure in patients with chronic kidney disease:the CRIC(chronic renal insufficiency cohort) study[J].J Am Heart Assoc,2017,6(5):e005336.
[12] 余雯枫,余毅.肾性贫血的诊治进展[J].世界临床药物,2018,39(3):211-216.
[13] 中国医师协会肾内科医师分会肾性贫血诊断和治疗共识专.肾性贫血诊断与治疗中国专家共识(2014修订版)[J].中华肾脏病杂志,2014,30(9):712-716.
[14] Shanahan CM,Crouthamel MH,Kapustin A,et al.Arterial calcification in chronic kidney disease:key roles for calcium and phosphate[J].Circ Res,2011,109(6):697-711.
[15] 贺丽娟,梁伟,熊子波.维持性血液透析患者血清钙磷及PTH水平与透析充分性的相关性[J].热带医学杂志,2018,18(10):1313-1316.
[16] 杨军,曾建,孙红亮.维持性血液透析患者血清钙磷及PTH水平与心脏结构功能的相关性[J].中国临床研究,2019,32(4):527-530.
[17] Bellasi A,Mandreoli M,Baldrati L,et al.Chronic kidney disease progression and outcome according to serum phosphorus in mild-to-moderate kidney dysfunction[J].Clin J Am Soc Nephrol,2011,6(4):883-891.
[18] Palmer SC,Hayen A,Macaskill P,et al.Serum levels of phosphorus,parathyroid hormone,and calcium and risks of death and cardiovascular disease in individuals with chronic kidney disease:a systematic review and meta-analysis[J].JAMA,2011,305(11):1119-1127.
[19] Tentori F.Mineral and bone disorder and outcomes in hemodialysis patients:results from the DOPPS[J].Semin Dial,2010,23(1):10-14.
[20] 刘丽茹,何敏华.维持性血液透析患者钙磷代谢及甲状旁腺素水平横断面调查[J].临床肾脏病杂志,2018,18(1):25-29.
[21] Combe C,Chauveau P,Laville M,et al.Influence of nutritional factors and hemodialysis adequacy on the survival of 1,610 French patients[J].Am J Kidney Dis,2001,37(1 Suppl 2):S81-S88.
[22] 宋佳,焦军东.评估血液透析患者营养状况的方法[J].中国中西医结合肾病杂志,2018,19(1):87-89.
[23] Harhay MN,Harhay MO,Coto-Yglesias F,et al.Altitude and regional gradients in chronic kidney disease prevalence in Costa Rica:data from the Costa Rican longevity and healthy aging study[J].Trop Med Int Health,2016,21(1):41-51.
[24] Otero González A,Iglesias Forneiro A,Camba Caride MJ,et al.Survival for haemodialysis vs.peritoneal dialysis and technique transference.Experience in Ourense,Spain,from 1976 to 2012[J].Nefrologia,2015,35(6):562-566.
[25] 朱永坚.老年人终末期肾病血液净化治疗的进展[J].临床与病理杂志,2017,37(11):2494-2499.
[26] 皇甫珍慧,胡晓舟,王少亭,等.老年维持性血液透析患者钙磷代谢紊乱情况及影响因素[J].中国老年学杂志,2015,35(24):7146-7148.
[27] Masakane I,Nakai S,Ogata S,et al.An overview of regular dialysis treatment in japan (as of 31 december 2013)[J].Ther Apher Dial,2015,19(6):540-574.
[28] Agarwal SK,Dash SC.Spectrum of renal diseases in Indian adults[J].J Assoc Physicians India,2000,48(6):594-600.
[29] Batista PB,Lopes AA,Costa FA.Association between attributed cause of end-stage renal disease and risk of death in Brazilian patients receiving renal replacement therapy[J].Ren Fail,2005,27(6):651-656.
[30] 吴小群.糖尿病肾病与非糖尿病肾病患者维持性血液透析疗效比较[J].医学综述,2012,18(14):2301-2302.