腹膜透析患者容量状态的临床研究

发布时间：2018-07-24 10:28

【摘要】：目的：腹膜透析是终末期肾脏病患者改善氮质血症、纠正液体平衡紊乱的重要措施之一，其中良好的容量控制是保证腹膜透析长期顺利进行的必要条件，与残肾功能等因素共同影响腹膜透析患者的预后。长期的容量负荷状态导致高血压、左心室肥厚、心功能不全等不良影响，同时促进炎症—营养不良的发生，增加死亡率。相反，容量不足可引起心脑血管缺血及残肾功能下降。临床观察当腹膜超滤量增加时，残余尿量相应减少，因此有学者提出让患者保持轻度的“湿化”状态以保护残肾功能。基于此，本研究应用多频生物电阻抗分析法评估维持性腹膜透析患者的容量状态，横断面分析容量状态与心血管系统的相关性，并探讨容量超负荷的预测因素，以期降低死亡率，延长生存时间。另外通过干预治疗降低患者容量负荷，旨在探讨容量超负荷对残肾功能的影响。方法：2013年7月至2014年2月期间随访于河北医科大学第三医院腹膜透析门诊，满足年龄在18岁至70岁，且透析时间3个月以上的维持性腹膜透析患者为研究对象，共入选67例。所有患者均应用生物电阻抗分析法检测容量状态(OH)，同时记录人口统计学资料、肾脏原发病、透析合并症及并发症、腹透相关情况、临床化验指标及超声心动图参数等。容量OH的测量方法：本研究应用的BCM（Body Composition Monitor，Fresenius Medical Care, Germany)其原理基于多频生物电阻抗分析法，BCM测得机体细胞外液(ECW)、总体水量(TBW)，并通过仪器内部公式自动求得患者的OH值（Overhydration），即机体超负荷的水。患者取仰卧位，四肢自然分开，平卧10分钟，身体不接触金属物体，用碘伏消毒右侧掌指关节、腕关节、跖趾关节、踝关节，在此四个部位贴电极片，连接BCM进行测定。依据BCM测定的OH值，分析容量与血压、心功能、残肾功能等指标的相关性。从横断面患者中选取满足残肾Kt/V≥0.1且尿量≥200ml/d的CAPD患者32例，排除观察期间死亡或退出腹膜透析者、观察期间严重的急性感染者（如腹膜炎）、观察期间严重机体内炎症反应者。该部分入选者每2-3个月进行BCM测量，每3个月进行实验室检查,同时对PD方案给予调节,观察时间6个月。依据OH值分为2组：基线OH＜2L或观察后OH降至＜2L，为OH1组；基线OH≥2L，（或）观察后OH≥2L，为OH2组。比较两组间残肾功能的下降速度，观察容量状态对残肾功能是否造成影响。采用SPSS18.0软件包进行统计分析。计量资料采用均值±标准差描述，两组间比较采用t检验或秩和检验；计数资料采用率或百分比描述，两组间比较采用卡方检验；等级资料采用秩和检验；双因素分析正态分布资料采用pearson相关分析，非正态分布资料采用spearman秩相关分析，P＜0.05认为有统计学差异。结果：1.符合纳入标准的67例患者，平均透析时间15.10±13.41个月，平均OH3.26±2.22L。按照OH＜2L和OH≥2L分为两组后，容量平衡组患者23例（34.3%），平均OH1.23±0.62L；容量超负荷组患者44例（65.7%），平均OH4.32±2.00L。两组间患者年龄、体重、身高、BMI、透析龄、腹透方式、腹膜转运特性等无统计学差异。而男性患者易出现容量负荷过重（vs女性，3.99±2.46L vs2.35±1.47L，P=0.002）。 2.横断面：41例患者（61.2%）临床表现心力衰竭，容量平衡组9例(13.4%)，按心功能分级（1、2、3、4级）分别占7.4%、6.0%、0%、0%，其中5例（7.5%）患者存在左心室肥厚；超负荷组32例(47.8%)，心功能分级（1、2、3、4级）分别为7.4%、17.9%、18.0%、4.5%，其中27例（40.3%）患者存在左心室肥厚。两组患者间残肾Kt/V、残肾Ccr、eGFR及残余尿量均无统计学差异（均P＞0.5）。相关性分析显示：OH与收缩压、舒张压、平均动脉压、左心室重量指数、心功能分级呈正相关（r值分别为0.37、0.29、0.22、0.37、0.63，P＜0.05），与白蛋白、血红蛋白、每周总Kt/V呈负相关（r值分别为-0.33、-0.35、-0.27，，P＜0.05）。但在排除残肾Kt/V=0的患者后发现OH与残肾Kt/V、eGFR呈负相关（r值分别为-0.35、-0.27，P＜0.05）。多元回归分析显示：高龄、男性、心功能不全、每周总Kt/V、白蛋白、血红蛋白与OH独立相关。 3.观察研究的相关性分析显示：残肾功能下降速度与基线OH及OH的改变不相关，但与基线残肾Kt/V、收缩压、平均动脉压呈正相关（r=0.685、0.36、0.366，P＜0.001）。将患者依据OH的改变分为两组后，两组间残肾功能下降速度无明显统计学差异。结论：长期的容量负荷状态是导致左心室肥厚和心功能下降等负面作用的重要因素之一，严重影响腹膜透析患者的生活质量及生存时间，需引起高度重视。男性、高龄、心功能差、每周总Kt/V降低、低血红蛋白、低血清白蛋白是腹膜透析患者容量状态的独立预测因素。容量超负荷不能作为残肾功能丧失的影响因素，同样对残肾功能也不具有保护作用。
[Abstract]:Objective: peritoneal dialysis is one of the important measures to improve azidemia and correct fluid balance disorder in patients with end-stage renal disease. Good volume control is a necessary condition to ensure the smooth progress of peritoneal dialysis for a long time. The prognosis of patients with peritoneal dialysis is affected by factors such as remnant kidney function. The long-term capacity load state leads to high blood pressure. Pressure, left ventricular hypertrophy, cardiac dysfunction and other adverse effects, and promote the occurrence of inflammation - malnutrition and increase the mortality. On the contrary, insufficient capacity can cause cardiovascular and cerebral ischemia and the decline of residual kidney function. Clinical observation when the peritoneal ultrafiltration increases, the residual urine volume decreases, so some scholars suggest that patients keep mild "humidification" "State to protect the function of the remnant kidney. Based on this, this study used multi frequency bioelectrical impedance analysis to evaluate the capacity status of patients with maintenance peritoneal dialysis, cross sectional analysis of the correlation between capacity and cardiovascular system, and explore the predictive factors of capacity overload in order to reduce mortality and prolong life. The purpose of this study was to investigate the effect of volume overload on residual renal function.
Methods: from July 2013 to February 2014, the patients were followed up in the peritoneal dialysis clinic of Third Hospital of Hebei Medical University. The patients aged from 18 to 70 years old and more than 3 months of dialysis time were studied and 67 cases were selected. All patients were detected by bioelectrical impedance analysis (OH) and recorded people at the same time. Statistical data, primary kidney disease, dialysis complications and complications, peritoneal dialysis related information, clinical laboratory indicators and echocardiographic parameters.
The measurement method of capacity OH: the principle of BCM (Body Composition Monitor, Fresenius Medical Care, Germany) is based on the multi frequency bioelectrical impedance analysis, and BCM is used to measure the outer liquid of the body (ECW) and the total amount of water (TBW), and the patient's excess water is obtained by the internal formula of the instrument. In the supine position, the supine position is taken, the limbs are naturally separated, the body is lying for 10 minutes, the body does not touch the metal objects, the right metacarpophalangeal joint, the wrist joint, the metatarsophalangeal joint and the ankle joint are sterilizing with Iodophor, and the four parts of the electrode are attached to the BCM to be measured. According to the OH value measured by BCM, the correlation between the volume and the blood pressure, cardiac function and the function of the remnant kidney is analyzed.
32 cases of CAPD patients with Kt/V more than 0.1 residual kidney and more than 200ml/d of urine were selected from the cross-sectional patients. The patients who died during the observation period or withdrawal from peritoneal dialysis were excluded. Severe acute infections (such as peritonitis) were observed during the observation period. During the observation period, severe inflammatory reactions in the body were observed. The participants were measured every 2-3 months by BCM, and every 3 months was carried out. At the same time, the PD scheme was adjusted and observed for 6 months. According to the OH value, the baseline was divided into 2 groups: the baseline OH < 2L or the observed OH to < 2L, OH1 group; the baseline OH is more than 2L, and (or) the OH > 2L, for the OH2 group. The decline rate of the remnant kidney function between the two groups was compared, and the effect of the capacity state on the remnant kidney function was observed.
The SPSS18.0 software package was used for statistical analysis. The measurement data were described with mean standard deviation. The two groups were compared with t test or rank sum test; the rate or percentage of the counting data was described. The two groups were compared with the chi square test; the rank data were tested by rank sum test; the dual factor analysis of normal distribution data was analyzed by Pearson correlation analysis, The data of non-normal distribution were analyzed by Spearman rank correlation analysis, P<0.05.
Results: 1. the average dialysis time was 15.10 + 13.41 months. The average OH3.26 + 2.22L. was two groups according to OH < 2L and OH > 2L. 23 cases (34.3%) in volume balance group, average OH1.23 + 0.62L, 44 patients (65.7%) in volume overload group, average age, weight, height, BMI, dialysis in the group of OH4.32 + 2.00L. two. Age, mode of peritoneal dialysis, and peritoneal transport characteristics were not significantly different. Male patients were prone to overcapacity (vs. females, 3.99 + 2.46L vs 2.35 + 1.47L, P = 0.002).
2. cross section: 41 patients (61.2%) clinical manifestations of heart failure, capacity balance group 9 cases (13.4%), according to the heart function grade (1,2,3,4 grade) accounted for 7.4%, 6%, 0%, 0%, 5 cases (7.5%) patients with left ventricular hypertrophy, 32 (47.8%) in the overload group (1,2,3,4 grade), respectively. Left ventricular hypertrophy. There was no statistical difference between the two groups of Kt/V, Ccr, eGFR and residual urine (all P > 0.5). Correlation analysis showed that OH was positively correlated with systolic pressure, diastolic pressure, mean arterial pressure, left ventricular weight index, cardiac function classification (r value was 0.37,0.29,0.22,0.37,0.63, P < 0.05, respectively), albumin, hemoglobin, and each The total Kt/V was negatively correlated (r value was -0.33, -0.35, -0.27, P < 0.05 respectively). But in the patients with remnant kidney Kt/V=0, OH was found to be negatively correlated with the remnant kidney Kt/V and eGFR (R is -0.35, < 0.05).
3. the correlation analysis of the observation study showed that the decline rate of the residual kidney function was not related to the changes of baseline OH and OH, but it was positively correlated with the baseline Kt/V, systolic pressure and mean arterial pressure (r=0.685,0.36,0.366, P < 0.001). The patients were divided into two groups according to the changes of OH, and there was no significant difference in the decline rate of the residual renal function between the two groups.
Conclusion: the long-term capacity load state is one of the important factors that cause the negative effects of left ventricular hypertrophy and decrease of heart function. It seriously affects the quality of life and life time of peritoneal dialysis patients. It needs to be highly valued. Male, elderly, poor heart function, low Kt/V per week, low hemoglobin and low serum albumin are peritoneal dialysis patients. Volume overload is not an independent predictor of residual renal function loss, nor does it protect residual renal function.
【学位授予单位】：河北医科大学
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：R692.5

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