不同血液净化方式对尿毒症患者高磷血症疗效的对比研究

发布时间：2018-10-22 15:18

【摘要】：目的:近年来多家研究证实,钙磷代谢紊乱是尿毒症患者面临的主要并发症之一。血磷升高是需行维持性血液透析的终末期肾病患者的心血管事件和死亡的重大独立危险因素。而改善钙磷代谢紊乱将大大改善患者的生存预后。目前对于维持性血液透析的患者来说,降磷的治疗措施主要有限制磷摄入、充分透析、使用磷结合剂以及必要时采用甲状旁腺切除术,几种方法各有优缺点。但究竟如何合理运用这几种方法,使得透析患者的血磷达标,仍是一个世界性的医学难题。目前的研究都显示,磷属于小分子尿毒素,单次普通血液透析、高通量血液透析、血液透析滤过、长时血液透析均能使血磷下降,但是究竟哪种透析方式的远期降磷效果好,并且能够显著改善患者的钙磷乘积、甲状旁腺激素水平,仍然没有定论。鉴于血液透析较为简便易行,尤其对于门诊透析患者来说,患者依从性较高,临床医生较易掌握,故此我们设计了本临床试验。本研究旨在探讨降低血磷的有效血液透析方式,以最大限度地改善尿毒症患者生存质量,延长患者生存时间。方法:选取邢台市人民医院血液净化室32名尿毒症患者,随机平均分为4组,以低磷饮食为治疗基础。各组患者的年龄、钙磷乘积、透析年限、甲状旁腺激素水平以及kt/v值均无统计学差异。A组接受普通血液透析(HD)3次/周(4h/次);B组接受普通血液透析2次/周(4h/次)加在线血液透析滤过(HDF)1次/周(4h/次);C组接受普通血液透析,每周2次,每次4小时,采用低通量型德朗空心纤维血液透析器,型号B-14P,膜材质聚醚砜,有效膜面积1.4m2。另外接受高通量血液透析,每周1次,采用透析器费森尤斯高通量透析器,透析器参数与B组进行HDF治疗时相同。D组患者接受LHD,每周3次,每次5小时。透析器参数同A组。治疗60天后检测血磷、血钙、钙磷乘积、甲状旁腺激素水平。结果:与A组相比,B、C、D 3组血磷、血钙、钙磷乘积、PTH指标明显改善,P0.05,差异具有统计学意义;D组血磷、血钙、钙磷乘积、PTH指标明显改善最为明显,与B、C 2组比较,P0.05,差异具有统计学意义。结论:血液透析滤过、高通量血液透析、长时血液透析均能改善维持性血液透析患者的高血磷状态,而长时血液透析对于降低血磷,降低钙磷乘积和甲状旁腺激素水平效果更为显著,值得临床推广。
[Abstract]:Objective: in recent years, many studies have confirmed that calcium and phosphorus metabolism disorder is one of the main complications of uremia patients. Elevated blood phosphorus is a significant independent risk factor for cardiovascular events and death in end-stage nephrotic patients undergoing maintenance hemodialysis. Improving calcium and phosphorus metabolism disorder will greatly improve the survival and prognosis of patients. At present, for maintenance hemodialysis patients, the main treatment measures of phosphorus reduction are limited phosphorus intake, adequate dialysis, the use of phosphorus binder and parathyroidectomy if necessary, several methods have their own advantages and disadvantages. However, how to use these methods reasonably to make the blood phosphorus of dialysis patients up to standard is still a worldwide medical problem. Current studies have shown that phosphorus is a small molecule of urotoxin, single ordinary hemodialysis, high-throughput hemodialysis, hemodiafiltration, and long-term hemodialysis can all lead to a decrease in blood phosphorus, but which dialysis method has a good long-term effect on phosphorus reduction. And can significantly improve the calcium-phosphorus product, parathyroid hormone levels, there is still no conclusion. Because hemodialysis is relatively simple, especially for out-patient dialysis patients, patient compliance is higher, clinicians are easier to master, so we designed this clinical trial. In order to improve the quality of life of uremic patients and prolong the survival time of uremic patients, the purpose of this study was to explore an effective hemodialysis method to reduce blood phosphorus. Methods: 32 patients with uremia in blood purification room of Xingtai people's Hospital were randomly divided into 4 groups. Age, calcium and phosphorus product, dialysis years, There was no significant difference in the level of parathyroid hormone and kt/v value. Group A received (HD) 3 times per week of hemodialysis (4h/ times); B group received 2 4h/ times per week) and online hemodiafiltration (HDF) once a week (4h/ times); C group). Under ordinary hemodialysis, Two times a week, each time 4 hours, using low flux Delang hollow fiber hemodialyzer, model B-14P, membrane material polyether sulfone, effective membrane area 1.4 m2. In addition, high flux hemodialysis was given once a week, and the parameters of dialyzer were the same as those of group B when treated with HDF. Group D received LHD, 3 times a week for 5 hours each time. The dialyzer parameters were the same as group A. Serum phosphorus, calcium, calcium product and parathyroid hormone levels were measured 60 days after treatment. Results: compared with group A, serum phosphorus, calcium, calcium and phosphorus product and PTH index in group D were significantly improved, while in group D, serum phosphorus, calcium, calcium and phosphorus, PTH were significantly improved. Compared with group B C 2, the difference was statistically significant (P 0.05). Conclusion: hemodiafiltration, high flux hemodialysis and long term hemodialysis can improve the state of high blood phosphorus in maintenance hemodialysis patients, while long term hemodialysis can reduce blood phosphorus. The effect of reducing calcium and phosphorus product and parathyroid hormone level is more obvious, and it is worth popularizing in clinic.
【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

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