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血管钙化是腹膜透析病人发生动脉粥样硬化、心肌梗死等心血管事件的重要危险因素[1]。但是目前尚无精确的检查方法来确定小血管或毛细血管的钙化或僵硬度情况,临床上多是用大动脉钙化的程度来间接反映全身血管钙化情况。2017年的全球肾脏病预后组织(kidney disease: improving global outcomes,KDIGO)实践指南[2]推荐应用腹部侧位X线片评估腹主动脉钙化(abdominal aortic calcification, AAC)情况来简洁反映全身血管钙化程度。腹膜透析主要利用腹膜两侧的毛细血管内血浆及透析液中的浓度梯度和渗透梯度,通过弥散及超滤原理清除体内过多的水分及代谢废物。充分的透析是长期透析病人健康生活的关键因素,透析不充分可发生容量超负荷及电解质代谢紊乱,进而导致高血压、左心室肥厚、充血性心力衰竭、钙磷代谢失调、血管钙化,严重者可能发生死亡[3]。加拿大《腹膜透析充分性指南》(2011)中将总尿素清除指数(Kt/V)作为透析充分性指标[4]。目前关于腹膜透析病人透析充分性与血管钙化的关系尚不明确。本研究旨在探讨维持性腹膜透析病人总Kt/V与AAC是否相关,从而为临床工作提供指导。
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本研究共纳入111例腹膜透析病人,其中无钙化组54例,钙化组57例,AAC检出率为51.4%。钙化组的年龄、透析龄、血磷、BNP均高于无钙化组(P < 0.05~P < 0.01);血红蛋白、总Kt/V、白蛋白、左心室射血分数均低于无钙化组(P < 0.05~P < 0.01)(见表 1)。
指标 无钙化组(n=54) 钙化组(n=57) t P 年龄/岁 47.74±13.17 61.75±9.56 5.60 < 0.01 透析龄[M(P25,P75)]/月 23.43(5.75, 36.00) 34.91(12.00, 48.00) 2.41△ < 0.05 男性[ n; 构成比(%)] 21(38.9%) 32(56.1%) 3.31* > 0.05 收缩压/mmHg 143.20±32.32 147.47±26.92 0.81 > 0.05 舒张压/mmHg) 92.00±20.22 89.13±20.87 0.74 > 0.05 糖尿病[ n; 构成比(%)] 7(13.0%) 11(19.3%) 0.82* > 0.05 BMI/(kg/m2) 22.57±3.83 23.24±3.83 0.92 > 0.05 血红蛋白/(g/L) 99.43±19.09 88.12±19.50 3.05 < 0.01 总Kt/V[M(P25,P75)] 2.36(1.72,2.77) 1.81(1.42,2.10) 3.53△ < 0.01 肌酐/(μmol/L) 843.30±305.27 956.14±347.03 1.82 > 0.05 尿素氮/(mmol/L) 16.49±5.95 18.28±7.04 1.44 > 0.05 校正钙/(mmol/L) 2.24±0.24 2.26±0.26 0.61 > 0.05 血磷/(mmol/L) 1.51±0.45 1.69±0.55 2.02 < 0.05 血钾/(mmol/L) 3.88±0.71 3.80±0.70 0.59 > 0.05 iPTH/(ng/L) 305.88±262.00 340.31±320.22 0.92 > 0.05 尿酸/(μmol/L) 393.07±91.42 411.51±105.25 0.99 > 0.05 白蛋白/(g/L) 33.80±3.60 29.90±5.38 3.98 < 0.01 总胆固醇/(mmol/L) 4.68±1.00 4.55±1.03 0.67 > 0.05 三酰甘油/(mmol/L) 1.81±1.22 1.98±1.69 0.65 > 0.05 BNP/(pg/mL) 376.61(56.50,389.00) 813.25(138.00,1266.50) 3.65△ < 0.01 左室射血分数[M(P25,P75)]/% 60.97(60.00,63.00) 59.47(59.00,61.50) 2.14△ < 0.05 肺动脉压力/mmHg 29.20±10.00 31.54±8.78 1.31 > 0.05 *示χ2值; △示Z值 表 1 临床相关资料的比较(x ± s)
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以AAC为因变量,以上述有统计学意义的年龄、透析龄、血磷、BNP、血红蛋白、总Kt/V、白蛋白、左心室射血分数变量为自变量,进行Spearman相关分析。结果显示,年龄、透析龄、血磷、BNP与AAC呈正相关(P < 0.05~P < 0.01),血红蛋白、总Kt/V、白蛋白、左心室射血分数与高AAC呈负相关(P < 0.05~P < 0.01)(见表 2)。
因素 r P 年龄 0.532 < 0.01 透析龄 0.229 < 0.05 血红蛋白 -0.291 < 0.01 总Kt/V -0.336 < 0.01 血磷 0.192 < 0.05 白蛋白 -0.379 < 0.01 BNP 0.348 < 0.01 左室射血分数 -0.204 < 0.05 表 2 AAC的相关因素分析(n=111)
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以有无钙化(有=1,无=0)为因变量,以上述有统计学意义的年龄、透析龄、血红蛋白、总Kt/V、血磷、白蛋白、BNP及左心室射血分数作为自变量,进行多因素logistic回归分析,结果显示,较高的年龄、较低的血红蛋白及总Kt/V下降是AAC的危险因素(P < 0.05~P < 0.01)(见表 3)。
因素 B SE Wald χ2 P OR(95% CI) 年龄 0.110 0.024 21.78 < 0.01 1.116(1.066~1.169) 血红蛋白 -0.034 0.013 6.53 < 0.05 0.966(0.941~0.992) 总Kt/V -1.107 0.370 7.55 < 0.01 0.362(0.175~0.747) 表 3 AAC的多因素logistic回归分析(n=111)
维持性腹膜透析病人总Kt/V与腹主动脉钙化的关系
Relationship between the total Kt/V and abdominal aortic calcification in maintenance peritoneal dialysis patients
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摘要:
目的探讨维持性腹膜透析病人总尿素清除指数(Kt/V)与腹主动脉钙化(AAC)的相关性。 方法选取于安徽医科大学第二附属医院腹膜透析中心规律随访并行腹部侧位X线片检查的腹膜透析病人111例。根据腹部侧位X线片是否存在AAC分为无钙化组54例和有钙化组57例。对2组病人的一般资料、实验室指标等临床相关资料及总Kt/V情况进行比较,并分析AAC发生的相关因素。 结果钙化组的年龄、透析龄、血磷及脑尿钠肽水平均明显高于无钙化组(P < 0.05~P < 0.01);而血红蛋白、总Kt/V、白蛋白、左心室射血分数均低于无钙化组(P < 0.05~P < 0.01)。Spearman多因素相关分析显示,年龄、透析龄、血磷、脑尿钠肽与AAC均呈正相关(P < 0.05~P < 0.01),血红蛋白、总Kt/V、白蛋白、左心室射血分数与AAC均呈负相关(P < 0.05~P < 0.01)。多因素logistic回归分析提示较高的年龄(OR=1.116,95%CI:1.066~1.169,P < 0.01)、较低的血红蛋白(OR=0.966,95%CI:0.941~0.992,P < 0.05)及总Kt/V下降(OR=0.362,95%CI:0.175~0.747,P < 0.01)是AAC的危险因素。 结论腹膜透析病人总Kt/V是AAC的独立危险因素。 Abstract:ObjectiveTo explore the correlation between the total urea clearance index(Kt/V) and abdominal aortic calcification(AAC) in maintenance peritoneal dialysis(PD) patients. MethodsA total of 111 PD patients with regularly followed up in the Peritoneal Dialysis Center of the Second Affiliated Hospital of Anhui Medical University and lateral abdominal X-ray examination were investigated.According to the presence or absence of AAC on lateral abdominal radiographs, the patients were divided into the non-calcification group(54 cases) and calcification group(57 cases).The general data, laboratory indicators and total Kt/V between two groups were compared, and the related factors of AAC were analyzed. ResultsThe age, dialysis time, serum phosphorus and natriuretic peptide levels in calcification group were significantly higher than those in non-calcification group(P < 0.05 to P < 0.01).However, the hemoglobin level, total Kt/V, albumin level and left ventricular ejection fraction in calcification group were significantly lower than those in non-calcification group(P < 0.05 to P < 0.01).The results of Spearman multivariate correlation analysis showed that the age, dialysis time, serum phosphorus and cerebrouretic natriuretic peptide levels were positively correlated with AAC(P < 0.05 to P < 0.01), while the hemoglobin level, total Kt/V, albumin, left ventricular ejection fraction were negatively correlated with AAC(P < 0.05 to P < 0.01).The results of multivariate logistic regression analysis showed that the higher age(OR=1.116, 95%CI: 1.066-1.169, P < 0.01), lower hemoglobin(OR=0.966, 95%CI: 0.941-0.992, P < 0.05) and decrease of total Kt/V(OR=0.362, 95%CI: 0.175-0.747, P < 0.01) were the risk factors of AAC. ConclusionsThe total Kt/V in PD patients is the independent risk factor of AAC. -
表 1 临床相关资料的比较(x ± s)
指标 无钙化组(n=54) 钙化组(n=57) t P 年龄/岁 47.74±13.17 61.75±9.56 5.60 < 0.01 透析龄[M(P25,P75)]/月 23.43(5.75, 36.00) 34.91(12.00, 48.00) 2.41△ < 0.05 男性[ n; 构成比(%)] 21(38.9%) 32(56.1%) 3.31* > 0.05 收缩压/mmHg 143.20±32.32 147.47±26.92 0.81 > 0.05 舒张压/mmHg) 92.00±20.22 89.13±20.87 0.74 > 0.05 糖尿病[ n; 构成比(%)] 7(13.0%) 11(19.3%) 0.82* > 0.05 BMI/(kg/m2) 22.57±3.83 23.24±3.83 0.92 > 0.05 血红蛋白/(g/L) 99.43±19.09 88.12±19.50 3.05 < 0.01 总Kt/V[M(P25,P75)] 2.36(1.72,2.77) 1.81(1.42,2.10) 3.53△ < 0.01 肌酐/(μmol/L) 843.30±305.27 956.14±347.03 1.82 > 0.05 尿素氮/(mmol/L) 16.49±5.95 18.28±7.04 1.44 > 0.05 校正钙/(mmol/L) 2.24±0.24 2.26±0.26 0.61 > 0.05 血磷/(mmol/L) 1.51±0.45 1.69±0.55 2.02 < 0.05 血钾/(mmol/L) 3.88±0.71 3.80±0.70 0.59 > 0.05 iPTH/(ng/L) 305.88±262.00 340.31±320.22 0.92 > 0.05 尿酸/(μmol/L) 393.07±91.42 411.51±105.25 0.99 > 0.05 白蛋白/(g/L) 33.80±3.60 29.90±5.38 3.98 < 0.01 总胆固醇/(mmol/L) 4.68±1.00 4.55±1.03 0.67 > 0.05 三酰甘油/(mmol/L) 1.81±1.22 1.98±1.69 0.65 > 0.05 BNP/(pg/mL) 376.61(56.50,389.00) 813.25(138.00,1266.50) 3.65△ < 0.01 左室射血分数[M(P25,P75)]/% 60.97(60.00,63.00) 59.47(59.00,61.50) 2.14△ < 0.05 肺动脉压力/mmHg 29.20±10.00 31.54±8.78 1.31 > 0.05 *示χ2值; △示Z值 表 2 AAC的相关因素分析(n=111)
因素 r P 年龄 0.532 < 0.01 透析龄 0.229 < 0.05 血红蛋白 -0.291 < 0.01 总Kt/V -0.336 < 0.01 血磷 0.192 < 0.05 白蛋白 -0.379 < 0.01 BNP 0.348 < 0.01 左室射血分数 -0.204 < 0.05 表 3 AAC的多因素logistic回归分析(n=111)
因素 B SE Wald χ2 P OR(95% CI) 年龄 0.110 0.024 21.78 < 0.01 1.116(1.066~1.169) 血红蛋白 -0.034 0.013 6.53 < 0.05 0.966(0.941~0.992) 总Kt/V -1.107 0.370 7.55 < 0.01 0.362(0.175~0.747) -
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