摘要
背景维持性血液透析(MHD)和腹膜透析(PD)是当前尿毒症患者主要的治疗方式,如何更好地制订治疗方案解决透析患者水负荷问题一直是临床研究的重要内容,应用体成分分析(BCM)对不同模式透析患者转归的影响仍有争议。目的研究BCM中的水负荷(OH)参数与MHD和PD患者预后的关系。方法纳入2017年10月—2022年3月在首都医科大学附属北京积水潭医院、北京博爱医院、航空总医院、北京市昌平区医院、北京市昌平区中西医结合医院维持性透析的334例患者为研究对象。根据患者采用肾脏替代治疗模式,将患者分为MHD组(n=188)和PD组(n=146)。通过电子病历系统收集患者一般资料,收集BCM相关参数。对纳入研究的患者进行随访,记录透析治疗参数、体质量、收缩压、舒张压,计算多次随访结果的平均值,随访期间记录终点事件,首要终点事件为全因死亡(ACM),次要终点事件包括心血管事件(CVE)、复合不良事件(CAE)、外科手术或骨折(SOF)。采用Spearman秩相关分析探究终点事件与BCM参数的相关性,多因素逐步Logistic回归分析探究患者发生次要终点事件的影响因素。采用Kaplan-Meier法绘制患者ACM生存曲线,采用Log-rank检验比较两组患者生存曲线的差异。采用多因素Cox回归分析探究患者ACM的影响因素。结果共311例患者完成了随访,中位随访时间29.9(18.0,36.0)个月,随访截至2022-09-30,其中MHD组176例,PD组135例完成了随访。MHD组透析龄、体质量、目标体质量、脂肪组织含量、脂肪含量、脂肪组织指数高于PD组,OH低于PD组(P<0.05)。MHD组体质量平均值、目标体质量平均值、收缩压平均值、脂肪组织含量平均值、脂肪组织指数平均值高于PD组,OH平均值、水负荷标准差(OHsd)、水负荷最大变化值(OHd)、水负荷最大变化值低于PD组。MHD组CVE、CAE、SOF的发生率分别为16.5%(29/176)、39.2%(69/176)、4.0%(7/176),PD组分别为45.9%(62/135)、83.0%(112/135)、8.2%(11/135)。MHD组CVE、CAE发生率低于PD组(χ^(2)=32.009,P<0.001;χ^(2)=60.132,P<0.001)。多因素Logistic回归分析结果显示MHD组细胞外水平均值/细胞内水平均值(OR=57.974,95%CI=1.393~2413.247)为CVE的影响因素(P<0.05),OHd(OR=1.255,95%CI=1.076~1.462)为CAE的影响因素(P<0.05);PD组患者年龄(OR=1.029,95%CI=1.008~1.052)为CVE的影响因素(P<0.05),OHd(OR=1.962,95%CI=1.355~2.842)为CAE的影响因素(P<0.05)。两组患者ACM的Kaplan-Meier生存曲线结果示,PD组ACM发生率高于MHD组(χ^(2)=7.145,P=0.008)。多因素Cox回归分析结果显示,年龄是MHD组ACM的影响因素(HR=1.070,95%CI=1.019~1.123),舒张压平均值(HR=0.942,95%CI=0.854~0.992)、OHsd(HR=3.612,95%CI=2.072~6.296)是PD组ACM的影响因素。结论PD患者首要终点事件、次要终点事件发生率高于MHD患者,且PD患者较MHD患者OH更明显,BCM所得OH值的波动可以预测PD患者的ACM。
Background Maintenance hemodialysis(MHD)and peritoneal dialysis(PD)are main treatment methods for uremic patients.It remains an important content of clinical research on better developing treatment protocols to address overhydration(OH)in dialysis patients,and the effect of applying body composition monitor(BCM)on the prognosis of dialysis patients treated with different dialysis models is still controversial.Objective To explore the relationship between OH parameters of BCM and prognosis in patients treated with MHD and PD.Methods From October 2017 to March 2022,334 patients on maintenance dialysis in Beijing Jishuitan Hospital affiliated to Capital Medical Medical University,Beijing Boai Hospital,Aviation General Hospital,Beijing Changping District Hospital and Beijing Changping Hospital of Integrated Traditional Chinese and Western Medicine were included as the study objects and divided into MHD group(n=188)and PD group(n=146)according to their renal replacement therapy mode.The general data of and BCM related parameters were collected through the electronic medical record system.Patients included in the study were followed up,dialysis treatment parameters,body weight,systolic blood pressure and diastolic blood pressure were recorded,and the average of multiple follow-up results were calculated.Endpoint events were recorded during follow-up period,with the primary endpoint event as all-cause death(ACM),secondary endpoint events as cardiovascular events(CVE),combined adverse events(CAE),surgery or fracture(SOF).Spearman rank correlation analysis was used to explore the correlation between endpoint events and BCM parameters,and stepwise multiple Logistic regression analysis was used to explore the influencing factors of secondary endpoint events in patients.The ACM survival curve was plotted by Kaplan-Meier method,and the difference of survival curve between the two groups was compared by Logrank test.Multivariate Cox regression analysis was used to explore the influencing factors of ACM.Results A total of 311 patients completed follow-up,with a median follow-up time of 29.9(18.0,36.0)months,including 176 patients in MHD group and 135 patients in PD group.Dialysis age,body weight,target body weight,adipose tissue content and adipose tissue index in MHD group were higher than those in PD group,and OH was lower than that in PD group(P<0.05).The mean values of body weight,target body weight,systolic blood pressure,adipose tissue content and adipose tissue index in MHD group were higher than those in PD group,while the mean value of OH,standard deviation of OH(OHsd),maximum change value of OH(OHd)and maximum change value of OH in MHD group were lower than those in the PD group(P<0.05).The incidence of CVE,CAE and SOF was 16.5%(29/176),39.2%(69/176)and 4.0%(7/176)in the MHD group,and 45.9%(62/135),83.0%(112/135)and 8.2%(11/135)in PD group,respectively.The incidence of CVE and CAE in MHD group was significantly lower than PD group(χ^(2)=32.009,P<0.001;χ^(2)=60.132,P<0.001).Multivariate Logistic regression analysis showed that the ratio of mean value of extracellular water to mean value of intracellular water in MHD group(OR=57.974,95%CI=1.393-2 413.247)was the influencing factor of CVE,OHd(OR=1.255,95%CI=1.076-1.462)was the influencing factor of CAE(P<0.05).The age of patients in PD group(OR=1.029,95%CI=1.008-1.052)was the influencing factor of CVE(P<0.05),and OHd(OR=1.962,95%CI=1.355-2.842)was the influencing factor of CAE(P<0.05).Kaplan-Meier survival curve of ACM between the two groups showed that the incidence of ACM in PD group was higher than that in MHD group(χ^(2)=7.145,P=0.008).Multivariate Cox regression analysis showed that age(HR=1.070,95%CI=1.019-1.123)was the influencing factor of ACM in MHD group(P<0.05),DBPm(HR=0.942,95%CI=0.854-0.992)and OHsd(HR=3.612,95%CI=2.072-6.296)were the influencing factors of ACM in PD group(P<0.05).Conclusion The incidence of primary endpoint event and secondary endpoint events in PD group was higher than that in MHD patients,and OH was more obvious in PD patients than MHD patients.The fluctuation of OH value obtained by BCM could predict ACM in PD patients.
作者
张东亮
马迎春
任建伟
王磊
赵景新
吝许亚
ZHANG Dongliang;MA Yingchun;REN Jianwei;WANG Lei;ZHAO Jingxin;LIN Xuya(Nephrology Department,Beijing Jishuitan Hospital affiliated to Capital Medical Medical University,Beijing 100035,China;Nephrology Department,China Rehabilitation Research Center/Beijing Boai Hospital,Beijing 100068,China;Nephrology Department,Aviation General Hospital,Beijing 100012,China;Nephrology Department,Beijng Changping Distirct Hsopital,Beijing 102200,China;Nephrology Department,Beijing Changping Hospital of Integrated Traditional Chinese and Western Medicine,Beijing 102200,China)
出处
《中国全科医学》
CAS
北大核心
2024年第21期2586-2591,共6页
Chinese General Practice
关键词
肾功能不全
肾透析
维持性血液透析
腹膜透析
体成分分析
不良结局
Renal insufficiency
Renal dialysis
Maintenance hemodialysis
Peritoneal dialysis
Body composition monitor
Adverse outcomes
