八段锦对腹膜透析患者临床疗效影响的非随机对照研究
发布时间：2018-08-18 20:32
【摘要】：目的:本研究通过先期的文献循证医学分析——系统评价和荟萃分析等文献分析方法。总结运动疗法在腹膜透析患者人群的具体应用以及指导方案。紧接着参照文献循证医学分析的证据,选择具有中医治疗保健作用的传统运动功法——八段锦,应用于本中心的腹膜透析患者人群中,研究八段锦传统运动功法对腹膜透析患者的疗效作用。揭示中医传统功法在腹膜透析患者人群中的治疗效果与应用规律,为中医临床的实践指导起到丰富和论证效果。方法:研究一:制定相关的检索策略,使用国内外的权威文献数据库,围绕"腹膜透析患者的运动干预研究"这个主题进行检索。运用文献定性与定量分析相结合的Review Manager 5.3软件对数据统计分析,包括定性的文献系统评价和定量的Meta分析。依据情况,采用不同的效应模型计算效应指标;适时行亚组分析及敏感分析等;并对结果进行森林图以及漏斗图展示。研究二:对在广东省中医院慢性疾病门诊中心规律随诊的腹膜透析患者,进行八段锦传统功法干预研究的筛查,纳入符合相关标准的受试对象。签署知情同意后,依照患者的意愿进行非随机化分配,运动组在日常活动中,进行八段锦传统功法习练,对照组维持原有的治疗和活动量;维持三个月的观察期后,比较两组间的干预前后各项指标的变化。研究三:探索八段锦传统功法在腹膜透析的抗氧化能力、微炎症状态以及免疫功能方面的作用,所以在研究二的基础上,抽取受试者的适量血液样本,采用双抗体一步夹心法酶联免疫吸附试验对总抗氧化能力(T-AOC)、超氧化物歧化酶(SOD)活性和丙二醛(MDA)含量、白细胞介素-2(IL-2)、白细胞介素-6(IL-6)、干扰素(INF-γ)和肿瘤坏死因子(TNF-a)等指标进行检测,对比干预前后的变化情况。结果:研究一:最终收录国内外文献7篇文献。共纳入254例腹膜透析患者。各研究间的观测时间跨度以及观测的结局指标有较大差异。观测时间跨度最大为10个月,最少的有8周。运动干预措施有散步、跑步、骑车、游泳、滑雪、太极等。运动干预的持续时间推荐20~30分钟为多。各个研究均具有可对比性,但在研究的随机方法上存在较大的风险以及提供的随机方案未能详尽提供。Meta分析结果,收缩压的总效应量,MD=8.16,95%CI 为 4.17~12.15,Z=4.01,P=0.0001;舒张压的 MD=4.24,95%CI 为0.85~7.62,Z=2.45,P=0.01;超滤量为MD=21.87,95%CI为6.05~37.70,Z=2.71,P=0.007;疲乏程度总效应量,MD=0.97,95%CI 为 0.77~1.16,Z=9.82,P0.01;以上几个指标均具有统计学意义。研究二:两组间的基线情况,年龄、性别、体重指数、原发性肾病、透析历龄、超滤量、残余尿量等均无统计学差异(P0.05)。生命体征方面,运动组干预前后收缩压、舒张压、心率的变化差异有统计学意义(P0.05);对照组的收缩压和舒张压前后比较,差异没有统计学意义(P0.05)。心率的差值,两组间的比较具有统计学差异(P0.05)。对照组的呼吸频率在观测期间的变化情况有统计学意义(P0.05),差值与运动组的比较具有统计学差异(P0.05)。能量代谢方面,静息能量消耗(REE)、静息能耗与阀值比(REE/Pred)的变化情况,两组均具有统计学意义(P0.05)。其他前后各项指标比较,差异均没有统计学意义(P0.05)。人体成分方面,肌肉容积(LTM)、体细胞含量(BCM)、脂肪组织含量(ATM)、脂肪含量(Fat)的前后各项指标比较,差异均没有统计学意义(P0.05)。运动组干预前后"过多水分"(0H)指标的变化情况,差异有统计学意义(P0.05);对照组观测期的ICW值在前后对照中,差异有统计学意义(P0.05)。营养指标方面,运动组干预前后皮褶厚度、体重指数、总蛋白、白蛋白、血钙、血清钠、血钾、葡萄糖、总胆固醇的变化差异均有统计学意义(P0.05);对照组的这些指标前后比较,差异没有统计学意义(P0.05)。研究三:两组间的总抗氧化能力、超氧化物歧化酶活性、白细胞介素-2、白细胞介素-6、干扰素和肿瘤坏死因子基线情况没有统计学差异(P0.05);丙二醛含量具有统计学意义(P0.05)。抗氧化能力方面,T-AOC和SOD活性,两组间的前后对比均具有统计学差异(P0.05),两组间的前后差值比较同样具有统计学意义(P0.05)。微炎症状态方面,IL-2和IL-6指标在两组间的前后对比均具有统计学差异(P0.05),两组间的前后差值比较无统计学意义(P0.05)。免疫系统功能方面,INF-丫和TNF-a,两组间的前后对比均具有统计学差异(P0.05),TNF-a的两组间前后差值比较有统计学意义(P0.05);INF-丫的两组间前后差值比较无统计学意义(P0.05)。结论:一、循证医学的荟萃分析总结,运动疗法对腹膜透析患者的收缩压和舒张压均具有改善作用,运动干预能够减低腹透患者的收缩压和舒张压。在日超滤量方面,运动干预同样具有促进作用,能提升腹膜透析患者的日超滤量,这也是腹膜透析患者血压下降的可能原因。在生活质量方面,运动能够改善透析患者的疲乏程度。二、八段锦传统功法对腹膜透析患者的临床疗效干预试验结果提示,八段锦运动疗法能够对腹透患者的收缩压和舒张压起到调节作用。八段锦传统功法干预可能对支配血管的交感神经起到兴奋性降低效果,从而对血管的舒张功能起到维持作用。心率方面,八段锦功法能够降低腹膜透析患者的心率。八段锦运动的段式本身具有"去心火"功效,对肾虚的虚火心悸、心率不齐等具有效果。呼吸频率方面,八段锦功法通过增强患者的呼吸功率,进而降低腹透患者的呼吸频率。三、能量代谢方面,八段锦功法可以提高腹膜透析患者的REE和REE/Pred水平。运动本身能够带来人体能量需求的增加,自身的基础代谢率相应得到提升。八段锦传统功法能够固护人体肾气,肾气的健旺进而促进机体新陈代谢。四、液体容量方面,八段锦传统功法可以减少腹膜透析患者的水液容量负荷。八段锦运动通过疏理人体三焦气机,运化脾胃传输功能并温化肾气对人体的水液代谢起到促进作用,祛除机体过多的液体容量负荷。五、营养指标方面,通过习练八段锦功法可以提高腹膜透析患者的营养状态。八段锦功法能够调理人体脏腑的功能,促进脾胃的运化,有助于对饮食精微物质的吸收,进而改善机体的营养状态。六、八段锦传统功法对腹膜透析患者的实验结果提示,习练八段锦功法可以提高腹膜透析患者的抗氧化能力。传统功法具有固护腰肾等作用,八段锦运动的调息练气,促进肾中精气的温阳化气,并转枢三焦调理全身气机,达到抗氧化作用。七、微炎症状态方面,八段锦传统功法可能具有降低腹膜透析患者的IL-6水平。通过减少促炎症因子的活性和数量,从而减少对机体肾脏的损害。腹膜透析患者的血清钙水平与腹膜透析患者的微炎症状态要结合起来研究。八、免疫功能方面,八段锦传统功法可以提高腹膜透析患者机体的免疫功能。八段锦运动能够扶正祛邪,增强人体的正气,对病邪的祛除以及疾病的康复具有正性作用,尤适于气虚型的肾病患者。建议慢性肾病患者应当加强运动疗法,尤其是在慢性肾脏病3期之后,对肾病的进展具有延缓的作用。九、本研究通过运用循证医学的文献研究方法,对腹膜透析患者的运动方案进行荟萃分析,为腹膜透析患者的八段锦运动临床干预提供了应用指导基础。八段锦传统功法的临床干预试验又为腹膜透析患者提供了一定的运动疗法医学证据和指导意见。发挥传统中医疗法在慢性肾脏病的防治优势,改善患者的生活质量和疾病状态,具有一定的可行性和有效性。
[Abstract]:OBJECTIVE: To summarize the specific application and guiding scheme of exercise therapy in peritoneal dialysis patients through literature evidence-based medicine analysis, such as systematic evaluation and meta-analysis. Baduanjin was applied to the peritoneal dialysis patients in our center to study the curative effect of Baduanjin traditional exercise method on the peritoneal dialysis patients. Relevant retrieval strategies were searched around the theme of "Sports Intervention Research in Peritoneal Dialysis Patients" using authoritative literature databases at home and abroad. Data were analyzed by Review Manager 5.3 software, which combines qualitative and quantitative analysis of literature, including qualitative literature system evaluation and quantitative meta-analysis. Different effect models were used to calculate effect indices, subgroup analysis and sensitivity analysis were performed in time, and forest maps and funnel maps were used to display the results. After signing the informed consent, the subjects were randomized according to the patients'wishes. In the exercise group, the traditional Baduanjin exercises were carried out in daily activities, while the control group maintained the original treatment and activity. After three months of observation, the changes of indexes before and after the intervention were compared between the two groups. The effects of traditional methods on the antioxidant capacity, Micro-inflammatory State and immune function of peritoneal dialysis patients were studied. On the basis of study 2, appropriate blood samples were taken and the total antioxidant capacity (T-AOC), superoxide dismutase (SOD) activity and malondialdehyde (MDA) content were measured by enzyme-linked immunosorbent assay (ELISA). Interleukin-2 (IL-2), interleukin-6 (IL-6), interferon-gamma (INF-gamma) and tumor necrosis factor (TNF-a) were measured before and after intervention, and the changes were compared. RESULTS: Study 1: 7 literatures were collected at home and abroad. A total of 254 peritoneal dialysis patients were enrolled in the study. The maximum observation time span is 10 months and the minimum observation time is 8 weeks. The intervention measures include walking, running, cycling, swimming, skiing, Tai chi, etc. The duration of exercise intervention is recommended to be more than 20-30 minutes. Meta analysis showed that the total effective dose of systolic blood pressure (MD = 8.16,95% CI = 4.17-12.15, Z = 4.01, P = 0.0001; MD = 4.24, 95% CI = 0.85-7.62, Z = 2.45, P = 0.01; ultrafiltration (MD = 21.87, 95% CI = 21.87, 95% CI = 6.05-37.70, Z = 2.71, Z = 2.71, P = 0.007; total effective dose of fatigdegree (MD = 0.97, 95% CI = 0.97, 95% CI = 0.97, 95% CI 0.77, 95% CI 0.77, 1.77, 1.95% CI 0.77, 1.77, 95% CI 0.77-1.01; above Study 2: There was no significant difference in baseline, age, sex, body mass index, primary nephropathy, duration of dialysis, ultrafiltration, residual urine volume between the two groups (P 0.05). The difference of heart rate between the two groups was statistically significant (P 0.05). The change of respiratory frequency in the control group was statistically significant (P 0.05), and the difference was statistically significant (P 0.05) compared with the exercise group. (REE), resting energy consumption and threshold ratio (REE / Pred) changes, the two groups were statistically significant (P 0.05). Other indicators before and after the comparison, the difference was not statistically significant (P 0.05). Human body composition, muscle volume (LTM), somatic cell content (BCM), fat tissue content (ATM), fat content (Fat) before and after the comparison of indicators, the difference was all significant. There was no statistical significance (P 0.05). The changes of "excessive water" (0H) index in the exercise group before and after the intervention were statistically significant (P 0.05); the ICW value in the control group during the observation period was statistically significant (P 0.05). Nutritional indicators, the exercise group before and after the intervention skin fold thickness, body mass index, total protein, albumin, blood calcium, serum. The changes of sodium, potassium, glucose and total cholesterol were statistically significant (P 0.05); there was no significant difference between the control group and the control group (P 0.05). There were statistical differences (P 0.05); Malondialdehyde content was statistically significant (P 0.05). Antioxidant capacity, T-AOC and SOD activity, before and after the comparison between the two groups were statistically significant (P 0.05), the difference between the two groups was also statistically significant (P 0.05). Micro-inflammatory state, IL-2 and IL-6 indicators in the two groups before and after the comparison. There was no significant difference between the two groups (P 0.05). In terms of immune system function, INF-Ya and TNF-a, there was significant difference between the two groups (P 0.05). The difference between the two groups of TNF-a was statistically significant (P 0.05). Conclusion: 1. Exercise therapy can improve the systolic and diastolic blood pressure of peritoneal dialysis patients, and exercise intervention can reduce the systolic and diastolic blood pressure of peritoneal dialysis patients. In terms of quality of life, exercise can improve the fatigue of dialysis patients. 2. The results of the intervention test of Baduanjin traditional Gong method on the clinical efficacy of peritoneal dialysis patients suggest that Baduanjin exercise therapy can regulate the systolic and diastolic blood pressure of peritoneal dialysis patients. Duan Jin's traditional skill intervention may reduce the excitability of sympathetic nerve innervating blood vessels and maintain the diastolic function of blood vessels. As for heart rate, Ba Duan Jin's skill therapy can reduce the heart rate of peritoneal dialysis patients. Respiratory frequency, Baduan Jingong method by enhancing the patient's respiratory power, thereby reducing the respiratory rate of peritoneal dialysis patients. 3, energy metabolism, Baduan Jingong method can improve the REE and REE/Pred levels of peritoneal dialysis patients. Baduanjin traditional methods can protect the human kidney Qi, kidney Qi and promote metabolism. 4, liquid capacity, Baduanjin traditional methods can reduce the volume of peritoneal dialysis patients with water load. Baduanjin exercise by regulating the human triple Jiao Qi machine, transporting the spleen and stomach function and warming the kidney Qi to the human body's water. Fluid metabolism plays a role in promoting the elimination of excessive body fluid volume load. Fifth, nutritional indicators, through the practice of Baduan Jingong method can improve the nutritional status of peritoneal dialysis patients. Baduan Jingong method can regulate the function of the human viscera, promote the operation of the spleen and stomach, help to absorb the fine substances of diet, and thus improve the operation of the body. Sixth, Baduanjin traditional Gong method of peritoneal dialysis patients with experimental results suggest that the practice of Baduanjin method can improve the antioxidant capacity of peritoneal dialysis patients. Seventh, the traditional method of Baduanjin may reduce the level of IL-6 in peritoneal dialysis patients. By reducing the activity and quantity of pro-inflammatory factors, thereby reducing the damage to the kidney. Peritoneal dialysis patients'serum calcium level and peritoneal dialysis patients' Micro-inflammatory State should be combined to study. Eighth, immunity. In terms of function, Baduanjin exercise can improve the immune function of peritoneal dialysis patients. Baduanjin exercise can strengthen the body's healthy qi, eliminate pathogens, especially for patients with kidney disease of Qi deficiency type. Ninth, through the use of evidence-based medicine literature research methods, peritoneal dialysis patients with exercise program meta-analysis, for peritoneal dialysis patients with Baduanjin exercise clinical intervention provides guidance. It also provides some medical evidence and guidance for peritoneal dialysis patients. It is feasible and effective to give full play to the advantages of traditional Chinese medicine in the prevention and treatment of chronic kidney disease and improve the quality of life and disease status of patients.
【学位授予单位】：广州中医药大学
【学位级别】：博士
【学位授予年份】：2017
【分类号】：R247.3
本文编号：2190599
[Abstract]:OBJECTIVE: To summarize the specific application and guiding scheme of exercise therapy in peritoneal dialysis patients through literature evidence-based medicine analysis, such as systematic evaluation and meta-analysis. Baduanjin was applied to the peritoneal dialysis patients in our center to study the curative effect of Baduanjin traditional exercise method on the peritoneal dialysis patients. Relevant retrieval strategies were searched around the theme of "Sports Intervention Research in Peritoneal Dialysis Patients" using authoritative literature databases at home and abroad. Data were analyzed by Review Manager 5.3 software, which combines qualitative and quantitative analysis of literature, including qualitative literature system evaluation and quantitative meta-analysis. Different effect models were used to calculate effect indices, subgroup analysis and sensitivity analysis were performed in time, and forest maps and funnel maps were used to display the results. After signing the informed consent, the subjects were randomized according to the patients'wishes. In the exercise group, the traditional Baduanjin exercises were carried out in daily activities, while the control group maintained the original treatment and activity. After three months of observation, the changes of indexes before and after the intervention were compared between the two groups. The effects of traditional methods on the antioxidant capacity, Micro-inflammatory State and immune function of peritoneal dialysis patients were studied. On the basis of study 2, appropriate blood samples were taken and the total antioxidant capacity (T-AOC), superoxide dismutase (SOD) activity and malondialdehyde (MDA) content were measured by enzyme-linked immunosorbent assay (ELISA). Interleukin-2 (IL-2), interleukin-6 (IL-6), interferon-gamma (INF-gamma) and tumor necrosis factor (TNF-a) were measured before and after intervention, and the changes were compared. RESULTS: Study 1: 7 literatures were collected at home and abroad. A total of 254 peritoneal dialysis patients were enrolled in the study. The maximum observation time span is 10 months and the minimum observation time is 8 weeks. The intervention measures include walking, running, cycling, swimming, skiing, Tai chi, etc. The duration of exercise intervention is recommended to be more than 20-30 minutes. Meta analysis showed that the total effective dose of systolic blood pressure (MD = 8.16,95% CI = 4.17-12.15, Z = 4.01, P = 0.0001; MD = 4.24, 95% CI = 0.85-7.62, Z = 2.45, P = 0.01; ultrafiltration (MD = 21.87, 95% CI = 21.87, 95% CI = 6.05-37.70, Z = 2.71, Z = 2.71, P = 0.007; total effective dose of fatigdegree (MD = 0.97, 95% CI = 0.97, 95% CI = 0.97, 95% CI 0.77, 95% CI 0.77, 1.77, 1.95% CI 0.77, 1.77, 95% CI 0.77-1.01; above Study 2: There was no significant difference in baseline, age, sex, body mass index, primary nephropathy, duration of dialysis, ultrafiltration, residual urine volume between the two groups (P 0.05). The difference of heart rate between the two groups was statistically significant (P 0.05). The change of respiratory frequency in the control group was statistically significant (P 0.05), and the difference was statistically significant (P 0.05) compared with the exercise group. (REE), resting energy consumption and threshold ratio (REE / Pred) changes, the two groups were statistically significant (P 0.05). Other indicators before and after the comparison, the difference was not statistically significant (P 0.05). Human body composition, muscle volume (LTM), somatic cell content (BCM), fat tissue content (ATM), fat content (Fat) before and after the comparison of indicators, the difference was all significant. There was no statistical significance (P 0.05). The changes of "excessive water" (0H) index in the exercise group before and after the intervention were statistically significant (P 0.05); the ICW value in the control group during the observation period was statistically significant (P 0.05). Nutritional indicators, the exercise group before and after the intervention skin fold thickness, body mass index, total protein, albumin, blood calcium, serum. The changes of sodium, potassium, glucose and total cholesterol were statistically significant (P 0.05); there was no significant difference between the control group and the control group (P 0.05). There were statistical differences (P 0.05); Malondialdehyde content was statistically significant (P 0.05). Antioxidant capacity, T-AOC and SOD activity, before and after the comparison between the two groups were statistically significant (P 0.05), the difference between the two groups was also statistically significant (P 0.05). Micro-inflammatory state, IL-2 and IL-6 indicators in the two groups before and after the comparison. There was no significant difference between the two groups (P 0.05). In terms of immune system function, INF-Ya and TNF-a, there was significant difference between the two groups (P 0.05). The difference between the two groups of TNF-a was statistically significant (P 0.05). Conclusion: 1. Exercise therapy can improve the systolic and diastolic blood pressure of peritoneal dialysis patients, and exercise intervention can reduce the systolic and diastolic blood pressure of peritoneal dialysis patients. In terms of quality of life, exercise can improve the fatigue of dialysis patients. 2. The results of the intervention test of Baduanjin traditional Gong method on the clinical efficacy of peritoneal dialysis patients suggest that Baduanjin exercise therapy can regulate the systolic and diastolic blood pressure of peritoneal dialysis patients. Duan Jin's traditional skill intervention may reduce the excitability of sympathetic nerve innervating blood vessels and maintain the diastolic function of blood vessels. As for heart rate, Ba Duan Jin's skill therapy can reduce the heart rate of peritoneal dialysis patients. Respiratory frequency, Baduan Jingong method by enhancing the patient's respiratory power, thereby reducing the respiratory rate of peritoneal dialysis patients. 3, energy metabolism, Baduan Jingong method can improve the REE and REE/Pred levels of peritoneal dialysis patients. Baduanjin traditional methods can protect the human kidney Qi, kidney Qi and promote metabolism. 4, liquid capacity, Baduanjin traditional methods can reduce the volume of peritoneal dialysis patients with water load. Baduanjin exercise by regulating the human triple Jiao Qi machine, transporting the spleen and stomach function and warming the kidney Qi to the human body's water. Fluid metabolism plays a role in promoting the elimination of excessive body fluid volume load. Fifth, nutritional indicators, through the practice of Baduan Jingong method can improve the nutritional status of peritoneal dialysis patients. Baduan Jingong method can regulate the function of the human viscera, promote the operation of the spleen and stomach, help to absorb the fine substances of diet, and thus improve the operation of the body. Sixth, Baduanjin traditional Gong method of peritoneal dialysis patients with experimental results suggest that the practice of Baduanjin method can improve the antioxidant capacity of peritoneal dialysis patients. Seventh, the traditional method of Baduanjin may reduce the level of IL-6 in peritoneal dialysis patients. By reducing the activity and quantity of pro-inflammatory factors, thereby reducing the damage to the kidney. Peritoneal dialysis patients'serum calcium level and peritoneal dialysis patients' Micro-inflammatory State should be combined to study. Eighth, immunity. In terms of function, Baduanjin exercise can improve the immune function of peritoneal dialysis patients. Baduanjin exercise can strengthen the body's healthy qi, eliminate pathogens, especially for patients with kidney disease of Qi deficiency type. Ninth, through the use of evidence-based medicine literature research methods, peritoneal dialysis patients with exercise program meta-analysis, for peritoneal dialysis patients with Baduanjin exercise clinical intervention provides guidance. It also provides some medical evidence and guidance for peritoneal dialysis patients. It is feasible and effective to give full play to the advantages of traditional Chinese medicine in the prevention and treatment of chronic kidney disease and improve the quality of life and disease status of patients.
【学位授予单位】：广州中医药大学
【学位级别】：博士
【学位授予年份】：2017
【分类号】：R247.3
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