腹膜透析对铁蛋白清除的临床研究

发布时间：2017-12-28 00:16

本文关键词：腹膜透析对铁蛋白清除的临床研究　出处：《河北医科大学》2015年硕士论文　论文类型：学位论文

【摘要】：目的:慢性肾脏病(Chronic kidney disease,CKD)患者随着肾功能的下降,体内促红细胞生成素(Erythropoietin,EPO)相对或者绝对减少,最终都会产生肾性贫血(Renal anemia,RA)[1],其发病率约为40%-60%,是CKD患者常见并发症之一[2]。导致肾性贫血的另一重要原因是缺铁,而血清铁蛋白(serum ferritin,SF)是铁在人体内的主要储存形式,其含量变化可作为判断铁缺乏和铁超载的指标。常规使用SF和转铁蛋白饱和度(Transferrin saturation,TSAT)作为铁状态的评价指标。既往的肾性贫血指南,包括最新的2013年《肾性贫血诊断与治疗中国专家共识》《肾性贫血诊断与治疗中国专家共识(2014修订版)》指出:非透析和腹膜透析患者TSAT20%,SF100 ug/L,血液透析患者SF200 ug/L时开始给予铁剂治疗;SF500 ug/L不常规应用静脉补铁治疗;TSAT"g50%和(或)SF"g800 ug/L应停止静脉补铁3个月。有研究报道血液透析(hemodialysis,HD)患者中有15%~22%存在绝对性铁缺乏,而腹膜透析(Peritoneal dialysis,PD)患者高达41%~45%存在绝对性铁缺乏[3]。2008年底,对上海市透析患者贫血治疗现况进行调查,发现PD组和HD组贫血治疗未达标率分别为60.72%和32.17%,说明仍有相当多的患者未达到治疗靶目标值,特别是PD组患者未达标率竟达到一半以上[4]。但是血液透析患者每次透析时,透析管路中或多或少都会丢失部分血,铁也会随之丢失,理论上应比PD患者贫血更不易达标,缺铁更严重,根据上面的研究显示,事实并非如此。PD患者可以通过腹膜透析清除体内的毒素,同时也会伴有营养物质的丢失,这些丢失的物质中是否包括铁蛋白及铁,铁蛋白及铁的丢失是否为PD患者贫血更不易达标及缺铁更严重的原因,目前相关研究报道很少。而且由于到目前还没有非透析与腹膜透析患者铁目标值的大样本RCT研究,所以非透析与腹膜透析患者铁剂治疗的目标值仍然是一样的。如果腹膜透析可以清除铁蛋白及铁,PD可能比非透析患者缺铁更严重,同样的铁剂治疗方案,也许不足以纠正PD患者的贫血。尽管铁蛋白低说明患者体内铁缺乏,会出现贫血,但是铁蛋白升高也会对PD患者产生多种危害。国外有研究表明:SF的升高是冠心病(Coronary heart disease,CHD)发生急性心肌梗死的危险因素之一[5],而心血管事件是透析患者死亡危险因素之首。此外最新研究表明,PD患者的残余肾功能(Residual renal function,RRF)与SF呈负相关,而且铁蛋白可加速残余肾功能的下降[6]。由此可以看出在腹膜透析患者中血清铁蛋白的浓度与贫血状况、残余肾功能、生活质量及预后密切相关,所以我们想通过本实验进一步了解腹膜透析患者中SF的水平与那些因素有关,以及腹膜透析对血清铁蛋白的清除情况。方法:选择2013年5月至2014年11月秦皇岛市第一医院肾内科维持性腹膜透析治疗患者25例。搜集患者的一般情况(性别、年龄、身高、体重、体质量指数(Body Mass Index,BMI)、透析龄、腹膜转运类型、KT/V、RRF、原发病、有无感染)。检测透析前空腹血红蛋白(hemoglobin,Hb)、白蛋白(albumin,Alb)、SF、血清铁(Fe)、转铁蛋白(transferring,TRF)、肌酐(Creatinine,Cr)、尿素氮(Blood urea nitrogen,BUN)、甲状旁腺激素(Parathyroid hormone,PTH)。检测透析后SF、Fe、TRF、Cr、BUN、PTH。计算Fe、TRF、Cr、BUN、PTH下降率(Removal rate,RR)。计录腹膜透析废液量,同时检测透析废液中Fe、TRF、Cr、BUN、PTH的浓度,并计算其相应清除总量(Total removal,TR)作为腹膜透析溶质清除的金标准。应用SPSS13.0统计软件进行统计分析。首先对透析前SF与年龄、身高、体重、BMI、透析龄、KT/V、RRF、感染、Hb、Alb进行两两相关性分析,再进行逐步多元线性回归分析进行校正;应用配对T检验分析透析前后溶质浓度变化是否具有统计学意义;应用Pearson相关分析透析前SF浓度与腹膜透析废液中SF浓度及清除总量相关性;应用Spearman秩相关分析SF与Fe、TRF、Cr、BUN、PTH下降率的相关性。结果:1经过两两相关分析筛选出感染、RRF、腹膜转运类型、Hb、BMI与腹膜透析前SF浓度具有相关性,进一步行逐步多元线性回归分析进行校正得出:透析前SF与感染、RRF有关(R=0.982,R2=0.964,P0.05),感染、RRF分别用X1、X2来表示,拟合方程为Y^=815.649+740.028X1-476.18X2,F=238.169,P0.001,该拟合方程差异具有计学意义。2腹膜透析前后Cr、BUN、PTH、TRF浓度差异具有统计学意义(分别的P=0.013、P=0.002、P=0.007、P=0.011)。透析前后SF、Fe浓度差异不具有统计学意义(P=0.288、P=0.068)。3腹膜透析液中SF浓度与透析前SF浓度呈正相关(r=0.636P=0.026)。4腹膜透析液中SF清除总量与透析前SF浓度呈正相关(r=0.618,P0.05)。5Spearman秩相关分析表明:SF下降率与Cr、BUN、Fe、TRF、PTH的下降率均不具相关性(P=0.070、P=0.218、P=0.265、P=0.336)。结论:1腹膜透析患者中血清铁蛋白与感染呈正相关,与残余肾功能呈负相关。2腹膜废液中能够检测到铁蛋白及铁离子,透析前血清铁蛋白浓度与腹膜透析液中的铁蛋白浓度及其清除总量均呈正相关,说明具有浓度依赖性。3腹膜对于铁蛋白的清除不同于肌酐等小分子、也不同于PTH中分子,所以腹膜透析对铁蛋白的清除机制有待进一步研究。
[Abstract]:Objective: chronic kidney disease (Chronic kidney, disease, CKD) in patients with decreased renal function, in vivo erythropoietin (Erythropoietin, EPO) the relative or absolute reduction, will eventually produce renal anemia (Renal anemia, RA [1]), the incidence rate is about 40%-60%, CKD is one of the common complications in patients with [2]. Another important reason leading to renal anemia is iron deficiency, and serum ferritin (SF) is the main storage form of iron in human body. Its content change can be used as an index for judging iron deficiency and iron overload. SF and transferrin saturation (Transferrin saturation, TSAT) were used as the criteria for the evaluation of iron status. Renal anemia guidelines of the past, including the latest 2013 "diagnosis and treatment of renal anemia China expert consensus" "diagnosis and treatment of renal anemia Chinese expert consensus (2014 Revision)" pointed out: non dialysis patients and peritoneal dialysis TSAT20%, SF100 ug/L, began treatment of blood dialysis patients given iron SF200 ug/L; iron SF500 ug/L on conventional intravenous; TSAT g50% and G800 ug/L (or SF) "should stop intravenous iron for 3 months. It has been reported that there is absolute iron deficiency in patients with hemodialysis (hemodialysis, HD), while patients with Peritoneal dialysis (PD) are as high as 41%~45%, and there is absolute iron deficiency [3] in patients with 15%~22%. By the end of 2008, Shanghai city conducted a survey of the present situation of anemia in dialysis patients treated, PD group and HD group without anemia treatment compliance rates were 60.72% and 32.17%, there is still a considerable number of patients did not reach the treatment target value, especially the PD group did not meet the rate has reached more than half of [4. However, in hemodialysis patients, more or less blood will be lost in hemodialysis, and iron will also be lost. Theoretically, anemia is more difficult than standard PD, and iron deficiency is more serious. According to the above research, it is not the case. PD by peritoneal dialysis patients can remove toxins from the body, but also accompanied by loss of nutrients, whether these substances include loss of ferritin and iron, ferritin and iron loss is less likely to cause anemia in patients with PD standard and more severe iron deficiency, the related research is rarely reported. And because there is no large sample RCT of non dialysis and peritoneal dialysis patients with iron target value, so non dialysis and peritoneal dialysis in patients with iron target value is still the same. If peritoneal dialysis can remove iron and ferritin, PD may be more severe than non dialysis patients with iron deficiency, iron treatment scheme is the same, may not be sufficient to correct anemia in patients with PD. Although low ferritin indicates iron deficiency in the patient's body, anemia may occur, but the increase of ferritin can also cause a variety of hazards to PD patients. Studies abroad show that the increase of SF is one of the risk factors of Coronary heart disease (CHD), and cardiovascular events are the leading cause of death risk in dialysis patients. In addition, the latest research shows that Residual renal function (RRF) in PD patients is negatively correlated with SF, and ferritin can accelerate the decline of residual renal function [6]. This can be seen in peritoneal dialysis patients with anemia and the concentration of serum ferritin in residual renal function, quality of life and is closely related to the prognosis, so we want to further understand this experiment in peritoneal dialysis patients SF levels associated with those factors, and peritoneal dialysis on serum ferritin clearance. Methods: from May 2013 to November 2014, 25 patients were treated with maintenance peritoneal dialysis in the nephrology department of Qinhuangdao First Hospital. The general condition of patients (gender, age, height, weight, Body Mass Index (BMI), age of dialysis, peritoneal transport type, KT/V, RRF, primary disease and infection) were collected. The fasting hemoglobin (hemoglobin, Hb), albumin (albumin, Alb), SF, serum iron (Fe), transferrin (transferring, TRF), creatinine (Creatinine, Cr), urea nitrogen (Blood Creatinine), and parathyroid hormone were detected before dialysis. SF, Fe, TRF, Cr, BUN and PTH were detected after dialysis. Calculate Fe, TRF, Cr, BUN, PTH drop rate (Removal rate, RR). The amount of peritoneal dialysis waste was counted, and the concentrations of Fe, TRF, Cr, BUN and PTH in dialysis waste were detected. The total clearance amount (Total removal, TR) was calculated as the gold standard for peritoneal dialysis solute clearance. SPSS13.0 statistical software was used for statistical analysis. The pre dialysis SF and age, height, weight, BMI, KT/V, RRF, dialysis age, infection, Hb, Alb 22 correlation analysis, and stepwise multiple linear regression analysis was corrected; using the paired T test to analyze whether the change of solute concentration before and after dialysis had statistical significance; Pearson correlation analysis was used to analyze pre dialysis SF the concentration of SF and peritoneal dialysis effluent concentration and removal of total correlation; correlation using Spearman rank correlation analysis of SF and Fe, TRF, Cr, BUN, PTH decline rate. Results: 1 after 22 related analysis showed that infection, RRF, Hb, BMI, peritoneal transport type and peritoneal dialysis before the SF concentration is relevant for further analysis of the correction of stepwise multiple linear regression: SF and pre dialysis infection, RRF (R=0.982, R2=0.964, P0.05, RRF) infection, respectively X1, X2 that equation is Y^=815.649+740.028X1-476.18X2, F=238.169, P0.001, the fitting equation difference is statistically significant. 2 the concentrations of Cr, BUN, PTH and TRF before and after peritoneal dialysis were statistically significant (P=0.013, P=0.002, P=0.007, P=0.011, respectively). There was no statistically significant difference in the concentration of SF and Fe before and after dialysis (P=0.288, P=0.068). 3 the concentration of SF in Liquor Dialysisintraperitoneus was positively correlated with the concentration of SF before dialysis (r=0.636P=0.026). 4 the total clearance of SF in Liquor Dialysisintraperitoneus was positively correlated with the concentration of SF before dialysis (r=0.618, P0.05). 5Spearman
【学位授予单位】：河北医科大学
【学位级别】：硕士
【学位授予年份】：2015
【分类号】：R692.5

【引证文献】