中国血液净化

中国血液净化 ›› 2023, Vol. 22 ›› Issue (06): 415-420.doi: 10.3969/j.issn.1671-4091.2023.06.004

• 临床研究 • 上一篇    下一篇

慢性肾脏病管理对糖尿病肾病进展及透析启动的影响

余 姝    贾 珏   王涛涛    徐凤兰     桂兰兰    华 琴   何建强   

  1. 212000 镇江，江苏大学附属医院 1肾脏内科 2 内分泌科 3 营养科 4临床药学
  • 收稿日期:2022-12-16 修回日期:2023-03-11 出版日期:2023-06-12 发布日期:2023-06-12
  • 通讯作者: 何建强 E-mail:hejq0305@163.com
  • 基金资助:
    镇江市科技创新(重点研发计划-社会发展)项目(SH2022036)

Effect of chronic kidney disease management on the disease progression and dialysis initiation in diabetic kidney disease patients

YU Shu, JIA Jue, WANG Tao-tao, XU Feng-lan, GUI Lan-lan, HUA Qin, HE Jian-qiang   

  1. Department of Nephrology, 2Department of Endocrinology, 3Department of Nutrition, and 4Department of Clinical Pharmacy, the Affiliated Hospital of Jiangsu University, Zhenjiang 212000, China
  • Received:2022-12-16 Revised:2023-03-11 Online:2023-06-12 Published:2023-06-12
  • Contact: 212000 镇江，江苏大学附属医院1肾脏内科 E-mail:hejq0305@163.com

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摘要： 目的  了解慢性肾脏病(chronic kidney disease,CKD)门诊管理对糖尿病肾病(diabetic kidney disease，DKD)患者疾病进展及透析启动的影响，为持续改进CKD多学科门诊管理及DKD管理提供依据。 方法  纳入2015年6月～2021年6月在江苏大学附属医院CKD管理门诊随诊并进入透析的92例DKD患者(管理组)，及同时期从肾脏内科专科门诊进入透析的94例DKD患者(非管理组)。比较2组患者首次透析时生化指标，血管通路，住院等情况以及肾功能进展情况，并分析各种因素对DKD病程进展的影响。 结果  进入透析时，管理组患者的收缩压、估算肾小球滤过率(eGFR)、全段甲状旁腺激素水平都低于非管理组(t值分别为-3.352、-1.196、-1.995；P值分别为0.001、0.047、0.047)，血红蛋白、血清白蛋白高于非管理组(t值分别为2.320、2.102；P 值分别为0.021、0.037)。首次血液透析时2组在血管通路、紧急透析及首次诱导透析占比间差异有统计学差异(χ2值分别为19.573、16.396、16.969，均P＜0.001)。Kaplan-Meier生存分析显示管理组进入透析的中位病程长于非管理组(t=2.239，P=0.021)。多因素分析的结果显示年龄、糖尿病视网膜病变(diabetic retinopathy,DR)、尿微量白蛋白/肌酐是DKD进展的危险因素(HR分别为1.020、0.554、1.000,95% CI 1.003～1.038、0.405～0.757、1.000～1.000,P分别为0.019、＜0.001、＜0.001)，CKD管理及使用血管紧张素转换酶抑制剂(ACEI)/血管紧张素Ⅱ受体拮抗剂(ARB)治疗可减缓DKD进展。 结论  慢性肾脏病管理能明显延缓DKD进展，在门诊管理中，注重DR的早期筛查和尿蛋白的管理，早期使用ACEI/ARB类药物，对延缓DKD进展有帮助。

关键词: 糖尿病肾病, 慢性肾脏病, 管理, 透析, 进展

Abstract: Objective  To evaluate the influence of chronic kidney disease (CKD) outpatient management on the disease progression and dialysis initiation in diabetic kidney disease (DKD) patients, so as to provide a basis for continuous improvement of the multidisciplinary management of CKD outpatients and DKD patients. Methods This study enrolled 92 DKD patients with initial hemodialysis from the CKD Outpatient Clinic (management group, group M) and 94 DKD patients with initial hemodialysis from the Nephrology Clinic (non-management group, group NM) in the Affiliated Hospital of Jiangsu University in the period from June 2015 to June 2021. Biochemical indexes, vascular access, hospitalization and renal function changes were compared between the two groups at the first dialysis. The impact of various factors on disease progression was evaluated by Cox regression analysis.  Results  At dialysis entry, systolic blood pressure, estimated glomerular filtration rate (eGFR), and serum whole parathyroid hormone were significantly lower in group M than in group NM (t=-3.352, -1.196 and -1.995 respectively; P=0.001, 0.047 and 0.047 respectively), and hemoglobin, serum creatinine and albumin were significantly higher in group M than in group NM (t=2.320, 2.189 and 2.102 respectively; P=0.021, 0.030 and 0.037 respectively); vascular access, emergent dialysis and the ratio of first induced dialysis at the first dialysis were significantly different between the two groups (c2=19.573, 16.396 and 16.969 respectively; P＜0.001). Kaplan-Meier survival analysis showed that the median disease course entering dialysis was significantly longer in group M than in group NM (t=2.239, P=0.21). Multivariate regression analysis showed that age, diabetic retinopathy, urinary microalbumin/creatinine were the risk factor for DKD progression (HR=1.020, 0.554 and 1.000 respectively, 95% CI: 1.003~1.038, 0.405~0.757 and 1.000~1.000 respectively; P=0.019, ＜0.001 and ＜0.001 respectively). CKD management and treatment with angiotensin converting enzyme inhibitors (ACEI)/angiotensin II receptor blocker (ARB) could postpone the DKD progression.  Conclusion  CKD management can significantly delay the progression of DKD. In outpatient management, early screening of diabetic retinopathy, management of urinary protein, and early use of ACEI/ARB medications are helpful to delay the DKD progression.

Key words: Diabetic kidney disease, Chronic kidney disease, Management, Dialysis, Progression

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