老年慢性肾脏病患者凝血异常的研究

发布时间：2018-06-22 01:11

本文选题：慢性肾脏病 + 高龄　；参考：《中国人民解放军医学院》2017年硕士论文

【摘要】：目的:回顾性队列研究慢性肾脏病(CKD) 5期高龄男性患者出血的相关危险因素及预后。方法:选取2009年1～2014年1月于解放军总医院老年肾脏病科住院治疗的143例CKD 5期患者,根据是否发生出血事件分为出血组和非出血组,分析比较两组患者的病史及血液理化指标的差异,并对所有患者进行为期12个月的回顾性队列预后的分析。结果:143例患者中,67例发生了出血,76例未发生出血。出血组患者中,发生消化道出血21例(31.3%)、皮肤黏膜或肌肉出血19例(28.3%)、眼底出血7例(10.4%)、齿龈出血10例(14.9%)、泌尿系出血8例(11.9%)、颅内出血2例(2.9%)。其中,发生主要出血事件患者有12例,包括消化道大出血5例、皮肤黏膜或肌肉组织出血4例、泌尿系出血1例、颅内出血2例。与非出血组的患者比较,出血组患者的年龄较大(88.99±4.53vs87.17±4.67,P=0.020)、肺部感染发生率[22(32.84%) vs 7(9.21%),P=0.000]、收缩压水平(145.74±15.80vs 138.5±17.06,P=0.010)、舒张压水平(72.28±12.21vs 66.49±10.72,P=0.003)、平均血小板体积(10.23±1.35 vs 10.81 ± 1 .57,P=0.021)、纤维蛋白原(4.09±0.75 vs 3.62±0.67,P=0.000)、血尿素氮(BUN)水平(37.19±10.66vs 32.86±8.97, P=0.009)较高,凝血酶原时间(13.54±1.02vs13.08±0.89,P=0.005)及活化部分凝血酶原时间(40.86±8.02vs 38.41±5.72, P=0.036)延长,差异有统计学意义(P0.05或P0.01)。Logistic回归分析发现感染、平均血小板体积、纤维蛋白原、BUN、收缩压是发生出血的独立危险因素(P0.05)。以3个月、6个月、12个月为观察点进行随访研究结果发现,出血组患者在3个月时发生全因死亡的人数明显高于非出血组,再发出血事件的人数及12月时再发主要出血事件的人数明显高于非出血组(P0.05)。结论:高龄男性CKD 5期患者容易发生出血并发症,且再发出血可能性较大。感染、平均血小板体积、纤维蛋白原、BUN、收缩压是发生出血的独立危险因素。目的:观察肾功能变化对老年人凝血功能及血小板参数的影响及临床意义方法:选取2015年1月～12月在解放军总医院南楼临床部查体的1055名老年人为研究对象,所有老年人根据估算的肾小球滤过率(eGFR)分为三组,A组(eGFR290 ml/min 1.73m2)共190例,平均年龄67.64±6.07岁,其中男性183例,女性7例,B组(60ml/min.1.73m2￡eGFR90ml/min+1.73m2)共695例,平均年龄73.24±11.35岁,其中男性659例,女性36例,C组(eGFR60 ml/min 1.73m2)共170例,平均年龄84.49±6.59岁,其中男性159例,女性11例。分析比较三组患者的血常规、凝血常规、肾功能及血栓弹力图指标等差异。结果:对三组老年人血常规、凝常规、肾功能、血栓弹力图等指标对比发现,随着eGFR降低,血红蛋白(148.91士9.39 vs 144.22±12.89 vs 133.14±17.13,P=0.000)、血小板计数(198.25±46.33 vs 184.54±48.17 vs 180.45±51.75,P=0.000)、白蛋白(46.26士2.1 vs45.10±2.6 vs43.33±3.4,P=0.000)、血尿素氮(5.38±1.26 vs6.06±1.45vs 8.8±3.56,P=0.000)、血尿酸(344.62±69.91 vs 348.39±68.76 vs 380.51±85.02,P=0.000)、血高密度脂蛋白(1.28±0.31 vs 1.32±0.66 vs 1.22±0.37,P=0.002),以上指标均呈降低趋势,差异有统计学意义(P0.01):常规凝血指标比较显示随着eGFR降低,血浆凝血酶原时间(12.73±0.56vs 12.98±0.94vs丨3.29±1.17,P=0.000)、血浆凝血酶原活动度(111.53±11.02vs 107.66±12.64vs 102.08±12.6,P=0.000)、国际标准化比值(0.94±0.05 vs 0.97士0.09 vs 1.00±0.12,P=0.000)、血浆纤维蛋白原(3.21±0.48 vs 3.28±0.55 vs 3.61±0.76,P=0.000)、血浆部分活化凝血酶原时间(35.13±3.39vs 35.24±3.39vs 36.64±4.5,P=0.000)均呈升高趋势,差异有统计学意义(P0.01);应用血栓弹力图(TEG,Thrombelastogram)比较三组老年人间的血小板功能发现随着eGFR降低R值(6.51士1.09 vs 6.2±1.11 vs 6.03±1.18,P=0.000)及K值(1.96±0.45vs 31.86±0.44 vs 1.62士0.46,P=0.000)明显缩短,α角(62.44±5.34vs63.84±5.27 vs 65.92±6.67,P=0.000)增大、MApiatelet(61.47±4.29vs 60.57±4.27 vs 57.78±5.9,P=0.000)降低,差异有统计学意义(P0.01);对MApiateiet升鬲的相关因素进行Pearsonx2分析发现eGFR、血红蛋白、红细胞比积、血白蛋白与MAplatelet升高呈正相关,血尿素氮、血肌酐、高血压、冠心病、心梗、年龄与其呈负相关;对MAplatelet升高的相关因素进行多元线性回归分析发现eGFR、血红蛋白、血小板比积、血白蛋白、血总蛋白、糖尿病是MAplatelet升高的独立危险因素。结论:老年人随着肾功能降低,血小板功能减低。eGFR、血红蛋白、血小板比积、血白蛋白、血总蛋白、糖尿病是血栓弹力图MAplatelet升高的独立危险因素。
[Abstract]:Objective: a retrospective cohort study of the related risk factors and prognosis of bleeding in 5 stage old male patients with chronic renal disease (CKD). Methods: 143 cases of CKD 5 patients hospitalized in the elderly Nephrology Department of the General Hospital of Liberation Army, 2009, in January, were divided into two groups according to whether bleeding parts were divided into hemorrhagic and non hemorrhagic groups. The difference in the patient's history and blood physical and chemical indexes and the retrospective cohort analysis of all patients for 12 months. Results: of the 143 patients, 67 had bleeding and 76 had no bleeding. 21 cases (31.3%) had hemorrhage in the hemorrhage group, 19 cases of skin skin mucosa or muscle bleeding (28.3%), and 7 cases of fundus hemorrhage (10.4%). There were 10 cases of gingival bleeding (14.9%), 8 cases of urinary bleeding (11.9%) and 2 cases of intracranial hemorrhage (2.9%). Among them, there were 12 cases of major bleeding events, including 5 cases of gastrointestinal hemorrhage, 4 cases of skin mucosa or muscle tissue bleeding, 1 cases of urinary bleeding and 2 cases of intracranial hemorrhage. Compared with the non bleeding group, the age of the bleeding group was larger (88.99 + 4.53). Vs87.17 + 4.67, P=0.020), the incidence of pulmonary infection was [22 (32.84%) vs 7 (9.21%), P=0.000], systolic blood pressure level (145.74 + 15.80vs 138.5 + 17.06, P=0.010), diastolic blood pressure level (72.28 + 12.21vs 66.49 + 10.72, P=0.003), average platelet volume (10.23 + 1.35 vs 10.81 +, P=0.021), fibrinogen, blood The levels of urea nitrogen (BUN) (37.19 + 10.66vs 32.86 + 8.97, P=0.009) were higher, prothrombin time (13.54 + 1.02vs13.08 + 0.89, P=0.005) and activated partial thromboplastin time (40.86 + 8.02vs 38.41 + 5.72, P=0.036) were prolonged. The difference was statistically significant (P0.05 or P0.01).Logistic regression analysis found infection, average platelet volume, fibrin BUN, systolic pressure was an independent risk factor for bleeding (P0.05). A follow-up study was conducted for 3 months, 6 months, and 12 months. The number of deaths in the bleeding group was significantly higher than that in the non bleeding group at 3 months, and the number of recurrent bleeding events and the number of major bleeding events in December were significantly higher than that of non blood groups. Hemorrhagic group (P0.05). Conclusion: bleeding complications are easy to occur in elderly male patients with stage CKD 5, and the possibility of recurrent bleeding is greater. Infection, average platelet volume, fibrinogen, BUN, systolic pressure are independent risk factors for bleeding. Objective: To observe the effect of renal function changes on blood coagulation function and platelet parameters in the elderly and clinical significance. Methods: 1055 elderly people were selected from January 2015 to December in the clinical department of the Southern Building of the General Hospital of the PLA. All aged people were divided into three groups based on estimated glomerular filtration rate (eGFR), and group A (eGFR290 ml/min 1.73m2), with an average age of 67.64 + 6.07 years, including 183 males, 7 females, and B group (60ml/min.1.73m2 & eGFR90). Ml/min+1.73m2) a total of 695 Cases, the average age of 73.24 + 11.35 years, of which 659 cases in males, 36 cases of women, and 170 cases of group C (eGFR60 ml/min 1.73m2), with an average age of 84.49 + 6.59 years, including 159 men and 11 women. Analysis and comparison of blood routine, coagulation, renal function and thromboelastogram index in group three. Results: the blood of three group of elderly people The routine, coagulation, renal function and thrombus map showed that with the decrease of eGFR, hemoglobin (148.91 and 9.39 vs 144.22 + 12.89 vs 133.14 + 17.13, P=0.000), platelet count (198.25 + 46.33 vs 184.54 + 48.17 vs 180.45 + 51.75, P=0.000), white protein (46.26 * 2.1 vs45.10 + vs43.33 + P=0.000), blood urea nitrogen (P=0.000), blood urea nitrogen 1.26 vs6.06 + 1.45vs 8.8 + 3.56, P=0.000), blood uric acid (344.62 + 69.91 vs 348.39 + 68.76 vs 380.51 + 85.02, P=0.000), blood high density lipoprotein (1.28 + 0.31 vs 1.32 + 0.66 vs 1.22 +%, P=0.002), the above indexes were decreased, the difference was statistically significant (P0.01): conventional coagulation index showed that with eGFR decreased, plasma coagulation The plasma prothrombin time (12.73 + 0.56vs 12.98 + 0.94vs 3.29 + 1.17, P=0.000), plasma prothrombin activity (111.53 + 11.02vs 107.66 + 12.64vs 102.08 + 12.6, P=0.000), the international standardized ratio (0.94 + 0.05 vs 0.97 0.09 vs 1 +, P=0.000), plasma fibrinogen (P=0.000), plasma part The active thromboplastin time (35.13 + 3.39vs 35.24 + 3.39vs 36.64 + 4.5, P=0.000) showed an increasing trend, and the difference was statistically significant (P0.01); the platelet function of the three groups of elderly patients was compared with eGFR (TEG, Thrombelastogram) to decrease the R value (6.51, 1.09 vs 6.2 + 1.11 vs 6.03 + 1.18, P=0.000) and K values (1.96 +). 0.45vs 31.86 + 0.44 vs 1.62, 0.46, P=0.000) obviously shortened, alpha angle (62.44 + 5.34vs63.84 + 5.27 vs 65.92 + 6.67, P=0.000) increased, MApiatelet (61.47 + 4.29vs 60.57 + 4.27 vs 57.78 + 5.9, P=0.000) decreased, and the difference was statistically significant (P0.01). The ratio of blood albumin to MAplatelet was positively correlated with blood urea nitrogen, blood creatinine, hypertension, coronary heart disease and myocardial infarction. Multiple linear regression analysis of the related factors of the elevated MAplatelet found that eGFR, hemoglobin, platelet ratio, serum albumin, blood total protein, and diabetes were independent risk for the increase of MAplatelet. Risk factors. Conclusion: the elderly patients with lower renal function, platelet function decreased.EGFR, hemoglobin, platelet ratio, blood albumin, blood total protein, diabetes is an independent risk factor for the increase of thrombus elasto map MAplatelet.
【学位授予单位】：中国人民解放军医学院
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R692

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