腹膜透析患者心脏瓣膜钙化的危险因素及对预后的影响

发布时间：2018-05-17 07:32

本文选题：腹膜透析 + 心脏瓣膜钙化　；参考：《苏州大学》2014年硕士论文

【摘要】：目的：评估苏州大学附二医院腹膜透析中心行腹透治疗的患者的营养状态，血压水平，钙磷代谢，生存预后等情况，研究心脏瓣膜钙化在腹膜透析患者中的特征，分析心脏主动脉瓣和二尖瓣钙化发病可能的危险因素，以及对预后的影响。方法：1.选取2006年以后进入我腹膜透析中心的117例规律腹膜透析患者为对象，患者行腹膜透析治疗时间均大于18个月。所有患者均由我院心超室进行心脏超声检查，评估有无主动脉瓣或二尖瓣钙化，根据心超结果分为主动脉瓣钙化(AVC)阳性组及阴性组，二尖瓣钙化(MVC)阳性组及阴性组。瓣膜钙化定义为主动脉瓣、二尖瓣瓣膜或瓣环出现1个或多个大于1mm的强回声。收集临床一般资料，并于清晨采空腹血，记录血常规、生化、电解质等。患者均于稳定状态下测定每周总KT/V，腹膜转运功能（PET）。采用横断面对比研究分析有瓣膜钙化组与无瓣膜钙化组的营养状态，透析充分性，钙磷代谢等指标，分析心脏瓣膜钙化可能的危险因素。 2.选取2009年01月至2011年12月苏州大学附属第二医院腹透中心开始透析治疗的终末期肾病患者112例，以开始进入透析治疗为观察起点，观察终点为2013年12月31日，随访终点事件为死亡或转为血液透析。所有患者均使用1.5%或2.5%葡萄糖腹膜透析液。以开始透析时是否合并心脏瓣膜钙化分为瓣膜钙化组及无瓣膜钙化组。计算患者进入透析时有效肾小球滤过率（rGFR）表示残余肾功能。采用非参数乘积限估计法（Kaplan-Meier）计算生存率，并用时序检验（Log-rank）对同类因素生存率进行显著性检验；采用Cox比例风险模型进行多因素拟合分析及相对危险度(RR）的比较。 3.采用统计软件SPSS17.0分析，p0.05认为有统计学意义。结果：1.（1）共有42例存在心脏瓣膜钙化，其中单纯二尖瓣钙化4例，单纯主动脉钙化25例，主动脉瓣和二尖瓣双瓣膜钙化13例。（2）与无主动脉瓣钙化组比较，有主动脉瓣钙化组患者年龄较大，CRP、低密度脂蛋白、总胆固醇较高，高血压病程较长，高血压病程与分级乘积数值较高，而前白蛋白偏低，差异有统计学意义。而血白蛋白、血红蛋白、血钙、血磷、钙磷乘积、iPTH均无显著差异。（3）与无二尖瓣钙化组比较，发生二尖瓣钙化的患者年龄较大，透析龄较长，血磷、钙磷乘积、CRP较高，前白蛋白较低，差异有显著意义。（4）多因素Logistic回归分析显示年龄(每增加10岁）、钙磷乘积与瓣膜钙化独立正相关，而前白蛋白与心脏瓣膜钙化独立负相关。（5）进一步分别以主动脉瓣钙化或二尖瓣钙化为因变量行单因素回归分析，P0.1的变量选为协变量进入多因素回归（后向法）分析。年龄/10(OR=1.965，p=0.01)、糖尿病史（OR=4.693，p=0.029）、钙磷乘积（OR=2.373，p=0.001）、前白蛋白（OR=0.908，p=0.012）与主动脉瓣钙化独立相关；年龄/10(OR=3.179，p=0.023)、钙磷乘积（OR=6.512，p=0.001）、前白蛋白（OR=0.885，p=0.033）、高密度脂蛋白（OR=19.540，p=0.011）、糖尿病史（OR=6.948，p=0.038）与二尖瓣钙化独立相关。（6）心脏瓣膜钙化组与无钙化组比较，左房内径明显增大，有显著性差异，射血分数（EF值），E/A值，左室后壁厚度，室间隔厚度等指标无显著差别。室间隔厚度及左室后壁厚度分别与高血压程度分级有相关关系，p0.05；左室舒张内径及左室收缩内径、瓣开放距离、E/A值分别年龄相关，p0.05。 2.（1）112例患者进入透析时有19例患者合并心脏瓣膜钙化，发病率16.96%。所有患者平均年龄为58.24±15.23岁，男性69例。在随访期间，26例患者死亡，112例患者总体生存时间为50.1±1.7月。（2）利用非参数乘积限估计法（Kaplan-Meier)计算无瓣膜钙化组的1年、2年、3年累积生存率分别为90.9%、86.2%、84.7%，有瓣膜钙化组1年、2年、3年累积生存率分别为89.5%、82.6%、24.1%。经Log-Rank检验进行比较：卡方值=21.126，P0.000，有显著性差异。（3）校正混杂因素后经多因素COX回归分析提示瓣膜钙化组死亡风险明显增加，RR=3.319，P=0.022，且独立于低前白蛋白水平，高龄等因素。结论：1.维持性腹膜透析患者心脏瓣膜钙化多发，，其中以主动脉瓣钙化更多见，年龄、糖尿病史、钙磷乘积、低前白蛋白血症是主动脉瓣钙化的独立危险因素，年龄、钙磷乘积、低前白蛋白血症是二尖瓣钙化的独立危险因素。 2.进入透析时合并心脏瓣膜钙化的腹透患者具有较高的死亡率，是影响预后的独立危险因素。
[Abstract]:Objective: To evaluate the nutritional status, blood pressure level, calcium and phosphorus metabolism and survival prognosis in the peritoneal dialysis center of the two hospital of Soochow University, to investigate the characteristics of cardiac valve calcification in peritoneal dialysis patients and to analyze the possible risk factors of cardiac aortic valve and mitral calcification, as well as the effect on prognosis.
Methods: 1. to select 117 regular peritoneal dialysis patients who entered my peritoneal dialysis center after 2006. The patients were treated with peritoneal dialysis for more than 18 months. All the patients were examined by cardiac ultrasound in our hospital. The calcification of the aortic valve or mitral valve was evaluated, and the aortic valve calcification (AVC) was divided according to the cardiac superresult. Positive group and negative group, mitral valve calcification (MVC) positive group and negative group. Valvular calcification was defined as aortic valve, mitral valve or valve ring appeared 1 or more than 1mm strong echo. Collect clinical general data, collect blood, record blood routine, biochemistry, electrosolution and so on in the early morning. Membrane transport function (PET). A cross-sectional study was used to analyze the nutritional status of valvular calcification group and no valvular calcification group, dialysis adequacy, calcium phosphorus metabolism and other risk factors for cardiac valve calcification.
2. selected 112 patients with end-stage renal disease from the center of The Second Hospital Affiliated to Suzhou University from 01 to December 2011 2009 to begin dialysis treatment to start dialysis treatment as the starting point. The end point was December 31, 2013, the end point of the follow-up was dead or converted to blood dialysis. All patients used 1.5% or 2.5% glucose peritoneum. The dialysate was divided into valvular calcification group and no valvular calcification group at the start of dialysis. The effective glomerular filtration rate (rGFR) was used to calculate the residual renal function during dialysis. The survival rate was calculated by the nonparametric product limit estimation (Kaplan-Meier), and the survival rate of similar factors was measured by time series test (Log-rank). The Cox proportional hazards model was used for multivariate analysis and relative risk (RR) comparison.
3. statistical software SPSS17.0 was used to analyze P0.05.
Results: 1. (1) there were 42 cases of cardiac valve calcification, including pure mitral calcification in 4 cases, simple aortic calcification in 25 cases, aortic valve and mitral valve calcification in 13 cases. (2) compared with the group without aortic valve calcification, the patients with aortic valve calcification were older, CRP, low density lipoprotein, higher total cholesterol, and a longer course of hypertension. There was no significant difference in blood albumin, hemoglobin, hemoglobin, blood calcium, blood phosphorus, calcium and phosphorus product, and no significant difference in iPTH. (3) compared with the non mitral valve calcification group, patients with mitral calcification had older age, longer dialysis age, blood phosphorus, calcium and phosphorus product, higher CRP, anterior white. The difference was significant. (4) multiple factor Logistic regression analysis showed that age (each increase of 10 years), calcium and phosphorus product was independent of valve calcification, and prealbumin was independently associated with cardiac valve calcification. (5) a single factor regression analysis was performed with aortic valve calcification or two apex calcification, and the variable of P0.1 /10 (OR=1.965, p=0.01), diabetes mellitus (OR=4.693, p=0.029), OR=2.373, p=0.001, OR=0.908, p=0.012 are independent of aortic valve calcification; age /10 (OR=3.179, p=0.023), calcium and phosphorus products, prealbumin, OR=19.540 (p=0.011) and diabetes history (OR=6.948, p=0.038) were independent of mitral calcification. (6) compared with the non calcification group, the cardiac valve calcification group was significantly increased in the left atrial diameter, and there were significant differences. There was no significant difference between the ejection fraction (EF), the E/A value, the left ventricular posterior wall thickness, the ventricular septum thickness and so on. The ventricular septal thickness and left ventricular septum thickness were not significant. The thickness of the posterior wall was related to the grade of hypertension, P0.05, the left ventricular diastolic diameter and the left ventricular systolic diameter, the open distance of the valve, and the age correlation of the E/A value respectively, p0.05.
2. (1) 112 patients entered dialysis with 19 patients with cardiac valve calcification. The average age of all patients with 16.96%. was 58.24 + 15.23 years and 69 men. In the follow-up period, 26 patients died and 112 patients had a total survival time of 50.1 + 1.7 months. (2) the non valvular calcification group was calculated by the non parametric product limit estimation (Kaplan-Meier). The cumulative survival rate of 1 years, 2 years and 3 years was 90.9%, 86.2%, 84.7% respectively. The cumulative survival rate of valve calcification group was 1 years, 2 years and 3 years, respectively, 89.5%, 82.6%, 24.1%. were compared by Log-Rank test: Chi square value =21.126, P0.000, significant difference. (3) correction of confounding after multiple factor COX regression analysis suggested that the risk of death in valve calcification group increased significantly Add, RR=3.319, P=0.022, and independent of low prealbumin level, age and other factors.
Conclusion: 1. the cardiac valve calcification in patients with maintenance peritoneal dialysis is more frequent, including more aortic valve calcification, age, diabetes history, calcium and phosphorus product, and low prealbumin as an independent risk factor for aortic valve calcification. Age, calcium and phosphorus product, and hypoalbuminemia are independent risk factors for mitral valve calcification.
2. peritoneal dialysis patients complicated with valvular calcification during dialysis have higher mortality rate and are independent risk factors for prognosis.
【学位授予单位】：苏州大学
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：R692.5

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