腹膜透析患者容量狀態(tài)的臨床研究
發(fā)布時(shí)間：2018-07-24 10:28
【摘要】：目的：腹膜透析是終末期腎臟病患者改善氮質(zhì)血癥、糾正液體平衡紊亂的重要措施之一，其中良好的容量控制是保證腹膜透析長(zhǎng)期順利進(jìn)行的必要條件，與殘腎功能等因素共同影響腹膜透析患者的預(yù)后。長(zhǎng)期的容量負(fù)荷狀態(tài)導(dǎo)致高血壓、左心室肥厚、心功能不全等不良影響，同時(shí)促進(jìn)炎癥—營(yíng)養(yǎng)不良的發(fā)生，增加死亡率。相反，容量不足可引起心腦血管缺血及殘腎功能下降。臨床觀察當(dāng)腹膜超濾量增加時(shí)，殘余尿量相應(yīng)減少，因此有學(xué)者提出讓患者保持輕度的“濕化”狀態(tài)以保護(hù)殘腎功能。基于此，本研究應(yīng)用多頻生物電阻抗分析法評(píng)估維持性腹膜透析患者的容量狀態(tài)，橫斷面分析容量狀態(tài)與心血管系統(tǒng)的相關(guān)性，并探討容量超負(fù)荷的預(yù)測(cè)因素，以期降低死亡率，延長(zhǎng)生存時(shí)間。另外通過(guò)干預(yù)治療降低患者容量負(fù)荷，旨在探討容量超負(fù)荷對(duì)殘腎功能的影響。 方法：2013年7月至2014年2月期間隨訪于河北醫(yī)科大學(xué)第三醫(yī)院腹膜透析門(mén)診，滿(mǎn)足年齡在18歲至70歲，且透析時(shí)間3個(gè)月以上的維持性腹膜透析患者為研究對(duì)象，共入選67例。所有患者均應(yīng)用生物電阻抗分析法檢測(cè)容量狀態(tài)(OH)，同時(shí)記錄人口統(tǒng)計(jì)學(xué)資料、腎臟原發(fā)病、透析合并癥及并發(fā)癥、腹透相關(guān)情況、臨床化驗(yàn)指標(biāo)及超聲心動(dòng)圖參數(shù)等。 容量OH的測(cè)量方法：本研究應(yīng)用的BCM（Body Composition Monitor，F(xiàn)resenius Medical Care, Germany)其原理基于多頻生物電阻抗分析法，BCM測(cè)得機(jī)體細(xì)胞外液(ECW)、總體水量(TBW)，并通過(guò)儀器內(nèi)部公式自動(dòng)求得患者的OH值（Overhydration），即機(jī)體超負(fù)荷的水。患者取仰臥位，四肢自然分開(kāi)，平臥10分鐘，身體不接觸金屬物體，用碘伏消毒右側(cè)掌指關(guān)節(jié)、腕關(guān)節(jié)、跖趾關(guān)節(jié)、踝關(guān)節(jié)，在此四個(gè)部位貼電極片，連接BCM進(jìn)行測(cè)定。依據(jù)BCM測(cè)定的OH值，分析容量與血壓、心功能、殘腎功能等指標(biāo)的相關(guān)性。 從橫斷面患者中選取滿(mǎn)足殘腎Kt/V≥0.1且尿量≥200ml/d的CAPD患者32例，排除觀察期間死亡或退出腹膜透析者、觀察期間嚴(yán)重的急性感染者（如腹膜炎）、觀察期間嚴(yán)重機(jī)體內(nèi)炎癥反應(yīng)者。該部分入選者每2-3個(gè)月進(jìn)行BCM測(cè)量，每3個(gè)月進(jìn)行實(shí)驗(yàn)室檢查,同時(shí)對(duì)PD方案給予調(diào)節(jié),觀察時(shí)間6個(gè)月。依據(jù)OH值分為2組：基線OH＜2L或觀察后OH降至＜2L，為OH1組；基線OH≥2L，（或）觀察后OH≥2L，為OH2組。比較兩組間殘腎功能的下降速度，觀察容量狀態(tài)對(duì)殘腎功能是否造成影響。 采用SPSS18.0軟件包進(jìn)行統(tǒng)計(jì)分析。計(jì)量資料采用均值±標(biāo)準(zhǔn)差描述，兩組間比較采用t檢驗(yàn)或秩和檢驗(yàn)；計(jì)數(shù)資料采用率或百分比描述，兩組間比較采用卡方檢驗(yàn)；等級(jí)資料采用秩和檢驗(yàn)；雙因素分析正態(tài)分布資料采用pearson相關(guān)分析，非正態(tài)分布資料采用spearman秩相關(guān)分析，P＜0.05認(rèn)為有統(tǒng)計(jì)學(xué)差異。 結(jié)果：1.符合納入標(biāo)準(zhǔn)的67例患者，平均透析時(shí)間15.10±13.41個(gè)月，平均OH3.26±2.22L。按照OH＜2L和OH≥2L分為兩組后，容量平衡組患者23例（34.3%），平均OH1.23±0.62L；容量超負(fù)荷組患者44例（65.7%），平均OH4.32±2.00L。兩組間患者年齡、體重、身高、BMI、透析齡、腹透方式、腹膜轉(zhuǎn)運(yùn)特性等無(wú)統(tǒng)計(jì)學(xué)差異。而男性患者易出現(xiàn)容量負(fù)荷過(guò)重（vs女性，3.99±2.46L vs2.35±1.47L，P=0.002）。 2.橫斷面：41例患者（61.2%）臨床表現(xiàn)心力衰竭，容量平衡組9例(13.4%)，按心功能分級(jí)（1、2、3、4級(jí)）分別占7.4%、6.0%、0%、0%，其中5例（7.5%）患者存在左心室肥厚；超負(fù)荷組32例(47.8%)，心功能分級(jí)（1、2、3、4級(jí)）分別為7.4%、17.9%、18.0%、4.5%，其中27例（40.3%）患者存在左心室肥厚。兩組患者間殘腎Kt/V、殘腎Ccr、eGFR及殘余尿量均無(wú)統(tǒng)計(jì)學(xué)差異（均P＞0.5）。相關(guān)性分析顯示：OH與收縮壓、舒張壓、平均動(dòng)脈壓、左心室重量指數(shù)、心功能分級(jí)呈正相關(guān)（r值分別為0.37、0.29、0.22、0.37、0.63，P＜0.05），與白蛋白、血紅蛋白、每周總Kt/V呈負(fù)相關(guān)（r值分別為-0.33、-0.35、-0.27，，P＜0.05）。但在排除殘腎Kt/V=0的患者后發(fā)現(xiàn)OH與殘腎Kt/V、eGFR呈負(fù)相關(guān)（r值分別為-0.35、-0.27，P＜0.05）。多元回歸分析顯示：高齡、男性、心功能不全、每周總Kt/V、白蛋白、血紅蛋白與OH獨(dú)立相關(guān)。 3.觀察研究的相關(guān)性分析顯示：殘腎功能下降速度與基線OH及OH的改變不相關(guān)，但與基線殘腎Kt/V、收縮壓、平均動(dòng)脈壓呈正相關(guān)（r=0.685、0.36、0.366，P＜0.001）。將患者依據(jù)OH的改變分為兩組后，兩組間殘腎功能下降速度無(wú)明顯統(tǒng)計(jì)學(xué)差異。 結(jié)論：長(zhǎng)期的容量負(fù)荷狀態(tài)是導(dǎo)致左心室肥厚和心功能下降等負(fù)面作用的重要因素之一，嚴(yán)重影響腹膜透析患者的生活質(zhì)量及生存時(shí)間，需引起高度重視。男性、高齡、心功能差、每周總Kt/V降低、低血紅蛋白、低血清白蛋白是腹膜透析患者容量狀態(tài)的獨(dú)立預(yù)測(cè)因素。容量超負(fù)荷不能作為殘腎功能喪失的影響因素，同樣對(duì)殘腎功能也不具有保護(hù)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.
【學(xué)位授予單位】：河北醫(yī)科大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2014
【分類(lèi)號(hào)】：R692.5
[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.
【學(xué)位授予單位】：河北醫(yī)科大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2014
【分類(lèi)號(hào)】：R692.5
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3 沈紅;葉華茂;;腹膜透析患者的退出及住院原因分析[A];中華醫(yī)學(xué)會(huì)腎臟病學(xué)分會(huì)2006年學(xué)術(shù)年會(huì)論文集[C];2006年
4 沈紅;葉華茂;;腹膜透析患者的退出及住院原因分析[A];中華醫(yī)學(xué)會(huì)第11屆全國(guó)內(nèi)科學(xué)術(shù)會(huì)議論文匯編[C];2007年
5 沈紅;葉華茂;;腹膜透析患者的退出及住院原因分析[A];2007年浙滬兩地腎臟病學(xué)術(shù)年會(huì)資料匯編[C];2007年
6 吳金土;巴震;姜毅;劉春雅;汪麗;;腹膜透析患者腹膜炎的誘發(fā)因素分析[A];2012年浙江省腎臟病學(xué)術(shù)年會(huì)論文集[C];2012年
7 陳妙芳;;131例腹膜透析患者退出腹膜透析原因分析[A];2011年浙江省中醫(yī)藥學(xué)會(huì)腎病分會(huì)學(xué)術(shù)年會(huì)暨國(guó)家級(jí)中醫(yī)藥繼續(xù)教育項(xiàng)目“慢性腎臟病臨床實(shí)踐與新進(jìn)展”學(xué)習(xí)班暨慢性腎臟病中醫(yī)臨床路徑學(xué)術(shù)研討會(huì)文集[C];2011年
8 劉洪濤;王亞平;姜德訓(xùn);霍延紅;高艷麗;王會(huì)接;;腹膜透析患者退出治療原因分析[A];“中華醫(yī)學(xué)會(huì)腎臟病學(xué)分會(huì)2004年年會(huì)”暨“第二屆全國(guó)中青年腎臟病學(xué)術(shù)會(huì)議”論文匯編[C];2004年
9 趙占正;王沛;肖靜;劉章鎖;;靜脈用鐵在腹膜透析患者貧血中的應(yīng)用探討[A];“中華醫(yī)學(xué)會(huì)腎臟病學(xué)分會(huì)2004年年會(huì)”暨“第二屆全國(guó)中青年腎臟病學(xué)術(shù)會(huì)議”論文匯編[C];2004年
10 林建雄;葉曉青;張小丹;易春燕;胡麗瓊;劉慶華;孫艷艷;張?jiān)品?羅伯s
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