维持性腹膜透析与血液透析患者钙磷代谢和心血管钙化比较的临床研究

发布时间：2018-08-03 18:02

【摘要】：目的：探讨腹膜透析（peritoneal dialysis，PD）与血液透析（hemodialysis，HD）患者钙磷代谢异常与心血管钙化（cardiovascular calcification，CVC）的关系及心血管钙化对维持性透析患者生存预后的影响；进一步比较腹膜透析和血液透析患者主动脉弓钙化的差异性和因素，以及透析患者生存预后的影响差异。方法：入选2011年1月1日至2013年12月31日期间于上海市第六人民医院腹膜透析治疗中心和血液透析治疗中心进行规律透析治疗的CKD5期患者。收集患者一般透析资料，身高、体重、血压、生化检验等指标，评估患者残余肾功能和透析充分性，记录患者胸部X线，评估主动脉弓钙化（aortic arch calcification，AoAC）程度，记录腹膜透析患者心超检查心脏瓣膜钙化（heart valve calcification，HVC）情况，透析患者用药情况。采用二元Logistics回归分析心脏瓣膜钙化和主动脉弓钙化独立危险因素；采用Kaplan-Meier生存分析心血管钙化对透析患者生存预后的影响；采用多变量COX回归分析透析患者死亡风险的独立危险因素；比较腹膜透析和血液透析患者主动脉弓钙化及生存预后情况，采用Kaplan-Meier生存分析透析主动脉弓钙化对采用不同透析方式的患者生存预后影响。结果：共收入腹膜透析患者177例，心脏瓣膜钙化病例50例（28.25%），单纯二尖瓣钙化（mitral valve calcification，MVC）11例，单纯主动脉瓣钙化（aortic valvecalcification，AVC）28例，二尖瓣及主动脉瓣均钙化病例11例，主动脉弓钙化病例66例（37.29%）。年龄和透析时间是腹膜透析患者心脏瓣膜钙化、主动脉弓钙化独立危险因素（P＜0.01）。血磷、钙磷乘积是腹膜透析心血管钙化的独立危险因素。血磷水平＞2.00mmol/L，心脏瓣膜钙化和主动脉弓钙化发生率明显增高，与≤1.50mmol/L相比，心脏瓣膜钙化（OR=4.271，95%CI1.702-10.714，P=0.001），主动脉弓钙化（OR=10.235，95%CI1.719-10.434，P=0.001）；钙磷乘积水平＞4.20mmol2/L2时，心脏瓣膜钙化和主动脉弓钙化发生率明显增高，与≤3.50mmol2/L2比较，心脏瓣膜钙化（OR=4.296，95%CI1.874-9.852，P=0.000），主动脉弓钙化（OR=6.750，95%CI3.014-15.118，P=0.000）。钙磷乘积是影响心脏瓣膜钙化的强独立危险因素（HR=2.739，95%CI1.578-4.755，P=0.000）；血磷是影响主动脉弓钙化的强独立危险因素（HR=45.167，95%CI8.914-228.850，P=0.000）。糖尿病肾病（diabetic kidney disease，DKD）患者心脏瓣膜和主动脉弓钙化发生风险分别是非糖尿病肾病患者的2.677倍和2.127倍。心脏瓣膜钙化病例生存率明显低于无瓣膜钙化者（Log-rank=6.832，P=0.009）；中度(重度)主动脉弓钙化病例生存率明显低于无钙化者（Log-rank=12.035，P=0.002），死亡风险为无钙化病例的6.167倍（P＜0.01）。收入血液透析病例147例，，主动脉弓钙化88例（59.86%）。钙磷乘积是影响血液透析患者主动脉弓钙化的强独立危险因素（HR=2.719，95%CI1.599-4.622，P=0.000）。钙磷乘积水平＞4.20mmol2/L2时，主动脉弓钙化发生率明显增高，与≤3.50mmol2/L2比较，OR=7.467，95%CI3.306-16.863，P=0.000。糖尿病肾病患者主动脉弓钙化发生风险是非糖尿病肾病患者的3.339倍。中度(重度)主动脉弓钙化病例生存率明显低于无钙化者（Log-rank=9.834，P=0.007），死亡风险为无钙化病例的24.429倍（P＜0.01）。在透析时间13-36月中，腹透病例主动脉弓钙化发生率低于血透病例（33.60%vs55.60%，P=0.025）；残余肾功能高于血透病例（3.54±3.14ml/min vs1.92±1.38ml/min，P=0.012）；钙磷乘积水平低于血透病例（4.09±1.06mmol2/L2vs4.75±1.36mmol2/L2，P=0.034）。血透病例中度(重度)主动脉弓钙化发生率高于腹透病例（26.53%vs19.77%，OR=2.096，95%CI1.204-3.652，P=0.008）。血透患者中，中度(重度)钙化病例生存率明显低于无钙化者（Log-rank=9.834，P=0.007）。在透析13-36月时间段中，腹透患者生存预后优于血透患者（9.70%vs22.20%，P=0.034），中度（重度）主动脉弓钙化对腹透病例和血透病例之间的影响无明显差异性（Log-rank=2.938，P=0.086）。结论：高血压、血脂、糖尿病是影响心血管钙化的传统危险因素，钙磷代谢异常是终末期肾病患者心血管钙化的又一重要危险因素。中度（重度）主动脉弓钙化是维持性腹膜透析和血液透析患者全因死亡的独立危险因子，心脏瓣膜钙化则是腹膜透析患者心血管疾病死亡的独立危险因子。腹膜透析更好的保护和延缓残余肾功能的丧失，从而更好的维持钙磷水平是主动脉弓钙化发生率低于血液透析患者的重要因素。中度（重度）主动脉弓钙化是终末期肾病透析患者死亡风险的强危险因子，但对腹膜透析和血液透析患者的风险影响无明显差异性。
[Abstract]:Objective:
The relationship between abnormal calcium and phosphorus metabolism and cardiovascular calcification (cardiovascular calcification, CVC) in patients with peritoneal dialysis (PD) and hemodialysis (hemodialysis, HD) and the influence of cardiovascular calcification on survival prognosis of patients with maintenance dialysis, and the difference of aortic arch calcification in peritoneal dialysis and hemodialysis patients. Heterosexual and factors, as well as the difference in survival prognosis of dialysis patients.
Method:
From January 1, 2011 to December 31, 2013, CKD5 patients in the Shanghai No.6 People's Hospital peritoneal dialysis treatment center and the hemodialysis treatment center were selected for regular dialysis treatment. The patients' general dialysis data, height, weight, blood pressure, biochemical test and other indicators were collected to assess the residual renal function and dialysis adequacy, and the patient was recorded. The degree of aortic arch calcification (aortic arch calcification, AoAC) was evaluated in the chest X-ray, and the cardiac valve calcification (heart valve calcification, HVC) in peritoneal dialysis patients was recorded and the medication of the dialysis patients was used. The independent risk factors of cardiac valve calcification and aortic arch calcification were analyzed by two yuan Logistics regression, and Kaplan was used for Kaplan. -Meier survival analysis of cardiovascular calcification on the survival of dialysis patients; multivariate COX regression analysis of independent risk factors for dialysis patients' death risk; comparison of aortic arch calcification and survival prognosis in peritoneal dialysis and hemodialysis patients and the use of Kaplan-Meier survival analysis to analyze the difference in aortic arch calcification. The survival prognosis of patients undergoing dialysis.
Result:
There were 177 cases of peritoneal dialysis, 50 cases of cardiac valve calcification (28.25%), 11 cases of mitral valve calcification (MVC), 28 cases of aortic valve calcification (aortic valvecalcification, AVC), 11 cases of mitral and aortic valve calcification, 66 cases of aortic arch calcification (37.29%). Age and dialysis time were Cardiac valve calcification and aortic arch calcification were independent risk factors (P < 0.01). Blood phosphorus, calcium and phosphorus product was an independent risk factor for cardiovascular calcification in peritoneal dialysis. The level of blood phosphorus was > 2.00mmol/L. The incidence of cardiac valve calcification and aortic arch calcification increased significantly. Compared with 1.50mmol/L, cardiac valve calcification (OR=4.271,95%CI1) .702-10.714, P=0.001), aortic arch calcification (OR=10.235,95%CI1.719-10.434, P=0.001); calcium and phosphorus product level > 4.20mmol2/L2, the rate of cardiac valve calcification and aortic arch calcification increased significantly, compared with < 3.50mmol2/L2, cardiac valve calcification (OR=4.296,95% CI1.874-9.852, P=0.000), aortic arch calcification (OR=6.750,95%CI3.014-15.1). 18, P=0.000). The calcium and phosphorus product is a strong independent risk factor (HR=2.739,95%CI1.578-4.755, P=0.000) affecting cardiac valve calcification; blood phosphorus is a strong independent risk factor for the calcification of the aortic arch (HR=45.167,95%CI8.914-228.850, P=0.000). Cardiac valve and aortic arch calcification in patients with diabetic nephropathy (diabetic kidney disease, DKD) The risk was 2.677 and 2.127 times as high as that of non diabetic nephropathy. The survival rate of heart valve calcification was significantly lower than that of no valvular calcification (Log-rank=6.832, P=0.009); the survival rate of moderate (severe) aortic arch calcification was significantly lower than that of non calcified cases (Log-rank=12.035, P =0.002), and the risk of death was 6.167 times (P < 0.01) (P < 0.01). ).
147 cases received hemodialysis and 88 cases of aortic arch calcification (59.86%). Calcium and phosphorus product was a strong independent risk factor (HR=2.719,95%CI1.599-4.622, P=0.000) affecting the calcification of aortic arch in hemodialysis patients. The incidence of aortic arch calcification increased significantly when calcium and phosphorus product level was > 4.20mmol2/L2, compared with 3.50mmol2/L2, OR=7.467,95%CI3.3 The risk of aortic arch calcification in patients with P=0.000. diabetic nephropathy was 3.339 times as high as that of non diabetic nephropathy. The survival rate of moderate (severe) aortic arch calcification was significantly lower than that of those without calcification (Log-rank=9.834, P=0.007), and the risk of death was 24.429 times as high as that of no calcification cases (P < 0.01).
In 13-36 months of dialysis, the incidence of aortic arch calcification was lower than that of hemodialysis (33.60%vs55.60%, P=0.025). The residual renal function was higher than that of hemodialysis (3.54 + 3.14ml/min vs1.92 + 1.38ml/min, P=0.012), and the level of calcium and phosphorus product was lower than that of hemodialysis (4.09 + 1.06mmol2/L2vs4.75 + 1.36mmol2/L2, P=0.034). The incidence of aortic arch calcification was higher than that of peritoneal dialysis (26.53%vs19.77%, OR=2.096,95%CI1.204-3.652, P=0.008). In hemodialysis patients, the survival rate of moderate (severe) calcification cases was significantly lower than those without calcification (Log-rank=9.834, P=0.007). In the 13-36 month period of dialysis, the survival of the patients with peritoneal dialysis was better than that of the hemodialysis patients (9.70%vs22.20%, P=0.034). There was no significant difference in the severity of aortic arch calcification between patients with peritoneal dialysis and hemodialysis cases (Log-rank=2.938, P=0.086).
Conclusion:
Hypertension, blood lipid, and diabetes are the traditional risk factors for cardiovascular calcification. Abnormal calcium and phosphorus metabolism is another important risk factor for cardiovascular calcification in patients with end-stage renal disease. Moderate (severe) aortic arch calcification is an independent risk factor for the death and death of patients in maintenance peritoneal dialysis and hemodialysis patients. Cardiac valve calcification is the peritoneum. An independent risk factor for the death of cardiovascular disease in dialysis patients. Peritoneal dialysis better protects and delays the loss of residual renal function, thus maintaining a better level of calcium and phosphorus is an important factor in the incidence of aortic arch calcification lower than that of hemodialysis patients. Moderate (severe) calcification of the aortic arch is a strong risk of death in end-stage renal dialysis patients. Risk factors, however, had no significant difference in the risk of peritoneal dialysis and hemodialysis.
【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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