中国血液净化

中国血液净化 ›› 2017, Vol. 16 ›› Issue (03): 162-166.doi: 10.3969/j.issn.1671-4091.2017.03.005

• 临床研究 • 上一篇    下一篇

单中心20年间维持性血液透析患者首次透析原因分析

徐冷楠1,赵班1,王海涛1,陈献广1,毛永辉1   

  1. 1. 北京医院 国家老年医学中心 肾内科
  • 收稿日期:2016-08-23 修回日期:2016-12-28 出版日期:2017-03-12 发布日期:2017-03-12
  • 通讯作者: 毛永辉 mmdn2009@163.com E-mail:xulengnan@126.com
  • 基金资助:

    北京医院院级科研课题（课题编号：BJ-2015-095）

Analysis of the causes of initiating dialysis in maintenance hemodialysis patients in a single center for 20 years

  • Received:2016-08-23 Revised:2016-12-28 Online:2017-03-12 Published:2017-03-12

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摘要： 目的分析北京医院肾内科血液净化中心20 年间血液透析患者原发病构成，糖尿病肾病(diabetic nephropathy,DN)患者及非DN 患者临床表现及首次透析原因差异，及血管通路使用情况。方法收集1994-2015 年间开始维持性血液透析(maintenance hemodialysis, MHD)的患者。记录患者原发病及导致首次透析的直接原因，开始透析时血管通路情况及首次透析前实验室检查结果。分析DN 和非DN 患者及前后10 年间上述指标差异。结果共收集289 例患者。肾小球肾炎、DN 和高血压肾病是前三位主要病因，DN 患者比例近10 年明显上升(16.000%上升至21.296%)。DN 患者开始MHD 时血肌酐水平低[(659.036 ± 350.533)μmol/L 对比(877.452 ± 386.593)μmol/L，t=3.789，P＜0.001]，贫血严重[(86.839±18.890)g/L 对比(93.092±22.795)g/L，t=2.064,P=0.041]、血磷[(1.648±0.481)mmol/L 对比(2.006 ± 0.753)mmol/L，t=3.865,P＜0.001]和全段甲状旁腺素(intact parathyroid hormone,iPTH) [(236.150±203.332)pg/ml 比(460.647±480.166)pg/ml,t=2.766,P=0.007)低，但酸中毒不明显(t=－2.483,P=0.014)。DN 患者进入MHD 的原因以心力衰竭/水肿为主，非DN 患者以尿毒症症状为主。近10 年所有患者血尿素氮明显升高(30.427±14.519mmol/L 比24.865±7.517mmol/L,t=-1.312,P=0.036)，但血钾[(4.676 ± 0.945)mmol/L 比(5.200 ± 0.745)mmol/L,t=1.880,P=0.037]、血钙[(2.154 ± 0.369)mmol/L 比(2.395 ± 0.270)mmol/L,t=2.033,P=0.037]、iPTH[(399.920 ± 435.836)pg/ml 比(968.000 ±705.377)pg/ml,t=2.399,P=0.020]控制明显优于10 年前。深静脉置管在进入MHD 时最常用。动静脉内瘘的比例无明显变化。结论北京医院肾内科血液净化中心MHD 患者的原发病构成中第1 位为肾小球肾炎，但DN 比例明显上升。DN 患者进入MHD 的时机更早，常因顽固心力衰竭/水肿开始首次血液透析。与10 年前相比，慢性肾脏病(chronic kidney disease,CKD)并发症控制更佳。但需重视CKD 患者AVF 的建立时机及使用。

关键词: 首次透析原因, 维持性血液透析, 原发病, 糖尿病肾病, 血管通路

Abstract: Objective To analyze the primary disease, the difference in clinical manifestation and the reason for initiating dialysis between diabetic nephropathy (DN) group and non-DN group, and the vascular access in the hemodialysis patients in our center in the recent 20 years. Methods We recruited the patients initiating the maintenance hemodialysis (MHD) during 1994 to 2015. Their primary disease, the direct cause leading to dialysis initiation, vascular access and laboratory tests were recorded. The differences in these parameters in DN and non-DN patients between the first 10-year period and the second 10-year period in 1994-
2015 were compared. Results A total of 289 patients were recruited. The leading primary disease was glomerulonephritis, followed by DN and hypertension. The proportion of DN patients increased significantly (16.000% to 21.296%) in the second 10-year period. At the initiating dialysis in DN patients, serum creatinine
level was relatively low (659.036±350.533 μmol/L vs. 877.452±386.593μmol/L, t=3.789, P＜0.001), anemia was relatively severe (86.839 ± 18.890 g/L vs. 93.092 ± 22.795 g/L, t=2.064, P=0.041), serum phosphorus (1.648±0.481 mmol/L vs. 2.006±0.753 mmol/L, t=3.865, P＜0.001) and iPTH (236.150±203.332 pg/ml vs. 460.647±480.166 pg/ml, t=2.766, P=0.007) were relatively low, and metabolic acidosis was not very heavy (t=-2.483, P=0.014). The direct cause to initiate hemodialysis was mainly heart failure/edema in DN group and uremic symptoms in non-DN group. In the second 10-year period, blood urea nitrogen (30.427±14.519 mmol/L vs. 24.865±7.517 mmol/L, t=-1.312, P=0.036) increased significantly in all patients, but serum potassium (4.676±0.945 mmol/L vs. 5.200±0.745 mmol/L, t=1.880, P=0.037), calcium (2.154±0.369 mmol/L vs. 2.395±0.270 mmol/L, t=2.033, P=0.037), and iPTH (399.920±435.836 pg/ml vs. 968.000±705.377 pg/ml, t= 2.399, P=0.020) were controlled better than those in the first 10year period. Most patients initiated hemodialysis with central venous catheterization as the blood access. The proportion of arteriovenous fistula (AVF) for blood access had no significant change. Conclusions The leading primary disease of MHD was glomerulonephritis in our center, but the proportion of DN as the primary disease increased significantly in recent 10 years. DN patients initiated MHD earlier and often due to the refractory heart failure/edema. Controlling of chronic kidney disease complications became better in the recent 10 years. We should carefully take account of the appropriate time to create and the use of AVF in CKD patients.

Key words: direct cause of the initial dialysis, maintenance hemodialysis, primary diseases, diabetic nephropathy, vascular access