中国血液净化

中国血液净化 ›› 2015, Vol. 14 ›› Issue (07): 412-417.doi: 10.3969/j.issn.1671-4091.2015.07.008

• 临床研究 • 上一篇    下一篇

维持性血液透析患者钙磷代谢紊乱回顾性分析

窦林斌,蔡宏,张伟明,朱铭力,陆任华,鲁嘉越,严玉澄,倪兆慧,钱家麒   

  1. 上海交通大学医学院附属仁济医院肾脏科
  • 收稿日期:2015-02-10 修回日期:2015-05-08 出版日期:2015-07-12 发布日期:2015-07-12
  • 通讯作者: 张伟明 weimingzh1965@163.com E-mail:weimingzh1965@163.com
  • 基金资助:

    上海交通大学医学院附属仁济医院南院临床学科创新共建平台建设项目(2014MDT02)

Retrospective analysis of calcium and phosphorus metabolism disturbances in maintenance hemodialysis patients

  • Received:2015-02-10 Revised:2015-05-08 Online:2015-07-12 Published:2015-07-12

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摘要： 【摘要】目的回顾性分析上海交通大学医学院附属仁济医院血液透析中心维持性血液透析(MHD)患者血清钙、磷、全段甲状旁腺激素(iPTH)检测结果，评价MHD 患者钙磷代谢状况。方法入选2007 年1 月1 日～2013 年12 月31 日七年期间，仁济医院血液透析中心透析龄大于等于3 个月MHD 患者528 例，随访患者从入选至患者死亡、终止血液透析、转肾移植、转其他中心、失随访或至研究终止日期的临床及实验室检查资料。所有入选患者每3 个月测定血清白蛋白、血钙，血磷，血iPTH。依据KDOQI 和KDIGO 指南血钙、磷和iPTH 靶目标，分析MHD 患者血总钙、血磷和血iPTH 达标率，并分析年龄、性别、透析频率、透析龄对血总钙、血磷和血iPTH 分布影响。结果患者平均年龄63.1±15.0 岁，其中男性295 例(占60.2%)。血总钙、血磷和iPTH 达标率分别为51.3%、39.0%, 26.1%。非老年患者(年龄小于65 岁)血磷和血iPTH 明显高于老年患者(年龄大于65 岁)[血磷(2.02±0.40 mmol/L vs. 1.75±0.40 mmol/L，P＜0.001)、iPTH[352.36(180.14,589.25)pg/ml vs. 223.76(122.36,381.82)pg/ml,P＜0.001)]。18% MHD患者iPTH 大于600pg/ml，25.6% MHD 患者iPTH 小于150pg/ml。每周3 次血液透析组血磷水平显著低于每周2 次血液透析组(1.87±0.42 mmol/L vs. 1.95±0.41 mmol/L，P=0.043)。而每周3 次血液透析组血钙水平显著高于每周2 次血液透析组(2.32±0.21mmol/L vs. 2.27± 0.22 mmol/L，P=0.022)。透析龄5 年及以上患者血总钙水平(2.35±0.22mmol/L vs. 2.23±0.18mmol/L，P＜0.0001)、血磷水平(1.95 ± 0.41mmol/L vs. 1.84 ± 0.44 mmol/L，P=0.027)、血iPTH 水平(443.17 ± 393.76pg/ml vs285.19±282.95pg/ml, P＜0.0001)都显著高于透析龄5 年以下患者。逐步多元线性回归分析显示血清白蛋白(P=0.001)、血钙(P＜0.001)、血iPTH(P＜0.001)、年龄(P＜0.001) 、透析龄(P=0.004)是影响血磷升高的独立危险因素。结论MHD 患者钙磷代谢控制尚不理想。与每周2 次透析相比，每周3 次透析可能更有利于控制血磷。透析龄大于5 年患者钙磷代谢更难以控制。血钙，血iPTH，血清白蛋白，年龄，透析龄是影响血磷水平的独立危险因素。

关键词: 维持性血液透析, 钙磷代谢紊乱, 透析龄

Abstract: 【Abstract】Objective There are only a few data at Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, about the prevalence and management of bone and mineral metabolism disorders in patients on maintenance hemodialysis (MHD). In this study, we retrospectively analyzed serum calcium, phosphorus and intact parathyroid hormone (iPTH) in the MHD patients treated in Hemodialysis Center of Ren Ji Hospital, and evaluated their calcium and phosphorus metabolism disturbances. Methods MHD patients treated in Ren Ji Hospital between Jan. 1, 2007 and Dec. 31, 2013 were enrolled in this study. They were followed up to the end-point of death, cessation of hemodialysis, transfer to other blood purification centers, or to the end of follow-up period (Dec. 31, 2013). Laboratory parameters including serum albumin, hemoglobin, phosphorus, calcium, iPTH, and high sensitivity C reactive protein (hs-CRP) were measured every 3 months. Result A total of 528 MHD patients (mean age 55.3±17.6 years, 60.8% males) were recruited in this study. Serum calcium, phosphorus and iPTH met the target levels suggested by the Kidney Disease Outcomes Quality Initiative (K/DOQI) accounted for 51.3%, 39.0% and 26.1%, respectively, of the patients. Serum calcium was higher in females (2.34±0.23 mmol/L) than males (2.28±0.20 mmol/L, P=0.024). Compared with younger
patients (age ＜65), older patients (age >65) had relatively lower phosphorus (1.75±0.40 vs. 2.02±0.40 mmol/ L, P＜0.001) and iPTH (223.76 pg/ml vs. 352.36 pg/ml, P＜0.001). iPTH >600 pg/ml was found in 18% patients, and iPTH ＜150 pg/ml in 25.6% patients. Patients with hemodialysis thrice a week had lower serum phosphorus and higher serum calcium than those with hemodialysis twice a week (1.87 ± 0.42 mmol/L vs. 1.95±0.41 mmol/L, P=0.043 for phosphorus; 2.32±0.21 mmol/L vs. 2.27±0.22 mmol/L, P=0.022 for calcium). Patients on MHD for more than 5 years had significantly higher serum calcium, phosphorus, and iPTH than those on MHD for less than 5 years (2.35±0.22 mmol/L vs. 2.23±0.18 mmol/L, P＜0.0001 for calcium; 1.95± 0.41mmol/L vs. 1.84 ± 0.44 mmol/L, P= 0.027 for phosphorus; 443.17±393.76 pg/ml vs. 285.19±282.95 pg/ml, P＜0.0001 for iPTH). Multiple and stepwise linear regression indicated that serum albumin (P=0.001), calcium (P＜0.001), iPTH (P＜0.001), age (P＜0.001) and dialysis vintage (P=0.004) were the independent risk factors for hyperphosphatemia. Conclusions Hyperphosphatemia and hyperparathyroidism were relatively common in MHD patients, especially in those with hemodialysis twice a week and those with hemodialysis vintage for more than 5 years. Serum albumin, calcium, iPTH, age and dialysis vintage were the independent risk factors for hyperphosphatemia.

Key words: Maintenance hemodialysis, Mineral and bone disorder, Dialysis vintage