维持性血液透析患者的临床及预后分析

Clinical and prognosis analysis of maintenance hemodialysis patients

摘要:

目的 回顾性分析单中心维持性血液透析患者的临床资料及预后。方法 收集2013年1月—2018年10月新疆医科大学第五附属医院血液净化中心透析龄≥ 3个月的维持性血液透析患者的病历资料，包括性别、年龄、透析龄、原发病、透析血管通路、血压、血生化指标、单室尿素清除指数（spKt/V）、药物使用情况等，对维持性血液透析患者的预后、生存率及相关因素进行分析。各种相关数据的采集通过全国血液净化病例登记系统完成。结果 共收集209例维持性血液透析患者，男性124例，女性85例，平均年龄（61.81±13.33）岁，中位透析龄40.50（27.50，62.00）个月。原发病：糖尿病肾病82例（39.23%），慢性肾小球肾炎63例（30.14%），高血压肾病22例（10.53％），多囊肾病10例（4.78％），梗阻性肾病8例（3.83%），狼疮肾炎8例（3.83％），急性肾损伤5例（2.39％），原因不详11例（5.27％）。动静脉内瘘150例（71.77%）、长期中心静脉导管56例（26.79％）、移植物动静脉内瘘2例（0.96%），临时导管1例（0.48%）。透析前平均收缩压为（148.17±19.84）mmHg。患者的平均血红蛋白水平为（100.13±21.01）g/L，铁蛋白水平为216.40（96.40，457.30）ng/mL，转铁蛋白饱和度为27.68（19.40，41.46）%，血钙水平为2.19（2.04，2.32）mmol/L，血磷水平为（1.62±0.56）mmol/L，iPTH水平为198.95（113.31，419.05）ng/L，平均血清白蛋白水平为（34.67±5.47）g/L。研究期间死亡70例（33.49%），心脑血管事件是患者死亡的主要原因，心血管疾病死亡41例，死亡原因第2位是感染。患者1年、3年、5年生存率分别为99.5%、83.5%、60.2%。COX回归分析结果显示，使用长期中心静脉导管［O^R=2.314（95% CI：1.269，3.590）］、spKt/V≥ 1.2［O^R=0.482（95% CI：0.204，0.820）］、使用磷结合剂［O^R=0.405（95% CI：0.227，0.720）］是患者全因死亡的独立危险因素（P <0.05）；年龄>60岁［O^R=2.824（95% CI：1.313，6.072）］、使用长期中心静脉导管［O^R=2.120（95% CI：1.043，4.306）］、透析前收缩压> 145 mmHg［O^R=3.547（95% CI：1.626，3.399）］、spKt/V ≥ 1.2［O^R=0.356（95% CI：1.172，0.732）］是患者心血管死亡的独立危险因素（P <0.05）。结论 该中心维持性血液透析患者的病因主要为糖尿病肾病和慢性肾小球肾炎；动静脉内瘘使用率偏低；心脑血管疾病为维持性血液透析患者的主要死因；透析充分性、生存率与发达国家或地区相比尚有一定差距。在治疗过程中，除关注血液透析外，还应积极探寻患者死亡的危险因素，予以干预，降低患者病死率。

Abstract:

Objective To analyze the clinical date and prognosis of MHD patients in our hemodialysis center.Methods We retrospectively reviewed the clinical records of MHD patients treated for more than 3 months in the blood purification center, the fifth affiliated Hospital of Xinjiang Medicial University, during January 2013 to October 2018. Gender, age, dialysis vintage, primary renal disease, vascular access type, blood pressure, blood biochemical index, spKt/V, cause of death, survival rate, and risk factors were analyzed. All related data were collected through the Chinese National Renal Data System.Results A total of 209 patients were recruited, 124 were males and 85 were females. The average age was (61.81 ± 13.33) years, and the median dialysis age was 40.50 (27.50, 62.00) months. The top 3 primary causes of ESRD were diabetic nephropathy (39.23%), glomerulonephritis (30.14%), and hypertensive nephrosclerosis (10.53%). Cuffed-tunneled catheters accounted for 26.79%, artificial blood vessels were used in 2 cases. The average level of hemoglobin (Hb) was (100.13 ± 21.01) g/L, the rate of Hb compliance was 25.83%, according to the standard of Hb between 110 to 120 g/L. The rates achieved to the recommended levels of blood calcium, blood phosphorus and iPTH were 56.46%, 52.15% and 43.10% respectively. The mean systolic blood pressure before dialysis was (148.17 ± 19.84) mmHg. During the follow-up period, 70 cases died (33.49%), of which 19.62% died of cardiovascular diseases, cardiovascular and cerebrovascular incidences were the leading causes of death, the second cause of death is infection. The survival rate of MHD patients was different: 99.5% in one year,83.5% in three years, and 60.2% in five years. Cox regression analysis showed that the use of long-term central venous catheter [O^R =2.314 (95% CI: 1.269, 3.590)], spKt / V ≥ 1.2 [O^R =0.482 (95% CI: 0.204, 0.820) ] and phosphorus binder [O^R =0.405 (95% CI: 0.227, 0.720)] were independent risk factors for all-cause death (P < 0.05). Age > 60 years [O^R =2.824 (95% CI: 1.313, 6.072)], use of long-term central venous catheter [O^R =2.120 (95% CI: 1.043, 4.306)], pre-dialysis systolic blood pressure> 145 mmHg [O^R =3.547 (95% CI: 1.626, 3.399)], spKt / V ≥ 1.2[O^R =0.356 (95% CI: 1.172, 0.732)] were independent risk factors for cardiovascular death (P < 0.05).Conclusions In our dialysis center, the etiology of maintenance hemodialysis patients is mainly diabetic nephropathy and chronic glomerulonephritis. The utilization rate of arteriovenous fistula is low. Cardiovascular and cerebrovascular diseases are the main cause of death in maintenance hemodialysis patients. There is still a certain gap in dialysis adequacy and survival rate compared with developed countries or regions. In the process of treatment, in addition to paying attention to hemodialysis, we should also actively explore the risk factors of patients' death, analyze and intervene to reduce the mortality of patients.