中国血液净化

中国血液净化 ›› 2016, Vol. 15 ›› Issue (10): 517-521.doi: 10.3969/j.issn.1671-4091.2016.10.002

• 临床研究 • 上一篇    下一篇

改善腹膜透析患者低白蛋白血症的临床路径及实施效果

陈元,全蕾,骆素平,田雪,董捷   

  1. 北京大学第一医院肾内科腹膜透析中心，北京大学肾脏疾病研究所，卫生部肾脏疾病重点实验室，慢性肾脏病防治教育部重点实验室(北京大学)
  • 收稿日期:2016-05-06 修回日期:2016-08-04 出版日期:2016-10-12 发布日期:2016-10-10
  • 通讯作者: 董捷 jie.dong@bjmu.edu.cn E-mail:eshajier@sina.com

Pathway to improve the hypoalbuminemia status in patients on peritoneal dialysis and its clinical effect

  • Received:2016-05-06 Revised:2016-08-04 Online:2016-10-12 Published:2016-10-10

RichHTML

1

PDF

288

摘要： 目的低白蛋白血症是维持腹膜透析蛋白质能量耗竭的常见表现，可预测患者的心血管事件和死亡率。改善低白蛋白血症对于提高腹膜透析患者临床预后具有重要意义。本研究欲建立改善腹膜透析患者低白蛋白血症的临床路径，并观察实施后的效果。方法本研究为病例自身前后对照设计，入选2014 年5 月1 日～10 月31 日期间北京大学第一医院肾脏内科的临床稳定的腹膜透析患者。根据影响腹膜透析患者低白蛋白血症的发生机制，设定临床路径查找具体原因，然后采取膳食指导、调整透析方案、容量控制、积极治疗合并症等一项或多项的干预性措施，分别观察调整后3 个月和6 个月时患者的血清白蛋白的水平。结果①本组腹膜透析患者共131 人，平均年龄(63.4±13.5)岁，男性58 人(44.3%),糖尿病76 人(58%)，中位透析龄为35(11～70)个月。导致低白蛋白血症的原因有合并症45 人(34.4%)；蛋白质热量摄入不足43 人(32.8%)；透析不充分4 人(3.1%)；容量超负荷4 人(3.1%)；蛋白丢失过多1 人(0.8%)；其他因素17 人(13%)；综合因素17 人(13%)。②实施以上干预措施后，血白蛋白水平从基线的(32.3±2.6)g/L 上升到3 个月时的(33.3±4.2)g/L 及6 个月时的(34.6±3.7)g/L；混合线性模型分析显示，经年龄、性别、透析龄校正后，上升趋势有显著的统计学意义(F =9.545，P＜0.001)。进一步对基线、3个月和6 个月的血清白蛋白水平进行两两比较(方差分析)，均有显著差异(3 个月和基线比较，P =0.032；6 个月和3 个月比较，P =0.021)。进一步分析显示，血白蛋白水平的上升趋势在糖尿病和非糖尿病组，透析龄≥36 月和＜36 月组，超敏C 反应蛋白≥4.06g/L 和＜4.06g/L 组的组间比较均无显著性差异。结论基于我们建立的改善低白蛋白血症的临床路径，可以有效改善腹膜透析患者的低白蛋白血症，此结果有待更大样本的研究证实。

关键词: 腹膜透析, 低白蛋白血症, 临床路径

Abstract: Objective Hypoalbuminemia is prevalent in patients on maintenance peritoneal dialysis (PD), which can predict cardiovascular events and mortality. Amelioration of the hypoalbuminemia is critical for the improvement of clinical outcome in PD patients. Our aim is to develop and implement a clinical pathway to improve the hypoalbuminemia and then to observe its efficacy. Methods This was a self- control study. Between May 1, 2014 and Oct. 31, 2014, we enrolled clinically stable PD patients from Peking University First Hospital. According to the mechanism for hypoalbuminemia, we developed a clinical pathway to root for the causes of hypoalbuminemia and then took measures including dietary counseling, dialysis regime adjustment, volume control, and dealing with comorbidities to improve serum albumin. We aimed to explore if these interventions could improve serum albumin after 3 months and 6 months. Results ①The average age of participants was 63.35 ±13.48 years, with 58 (44.3%) men, and 76 (58%) diabetes. The median dialysis duration was 35 (11～70) months. The causes for hypoalbuminemia were comorbidities (45, 34.4%), insufficient protein and calorie intake (43, 32.8%), inadequate dialysis (4, 3.1%), volume overload (4, 3.1%), loss of protein (1, 0.8%), other factors (17, 13%), and miscellaneous (17, 13%). ②By general linear model analysis, serum albumin significantly increased to 33.3±4.2 g/L at the 3rd month and 34.6±3.7g/L at the 6th month from the baseline value after adjusting for age, gender and dialysis duration. Serum albumin values at the 6th month were also higher than those at the 3rd month (P=0.021) and at the baseline (P=0.032). Further analysis showed that the increasing trend of serum albumin was comparable between non-diabetes and diabetes, patients with dialysis duration longer and shorter than 36 months, and patients with high- sensitive C-reactive protein higher and lower than 4.06 g/L. Conclusions Based on the clinical pathway for ameliorating hypoalbuminemia in PD patients, we can significantly increase the value of serum albumin. The finding needs to be verified in further studies with large sample sizes.

Key words: Peritoneal dialysis, hypoalbuminemia, clinical pathway