中国血液净化

中国血液净化 ›› 2017, Vol. 16 ›› Issue (08): 533-536.doi: 10.3969/j.issn.1671-4091.2017.08.008

• 临床研究 • 上一篇    下一篇

持续质量改进对维持性血液透析患者矿物质骨代谢的影响

漆映辉1,曲晓璐1,杜美莲1,张善宝1,乔诚1,王小玉1,刘晨1,倪兆慧2   

  1. 1上海浦东新区浦南医院肾内科
    2上海交通大学医学院附属仁济医院肾脏科
  • 收稿日期:2017-06-05 修回日期:2017-06-18 出版日期:2017-08-12 发布日期:2017-08-12
  • 通讯作者: 倪兆慧 profnizh@126.com E-mail:qwe1968@sina.com
  • 基金资助:

    上海市浦东新区卫计委学科带头人培养计划附带课题(PDRd2013-07)

Effect of continuous quality improvement on mineral bone metabolism in maintenance hemodialysis patients

  • Received:2017-06-05 Revised:2017-06-18 Online:2017-08-12 Published:2017-08-12

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摘要： 目的探讨持续质量改进这一管理方法对纠正维持性血液透析(maintenance hemodialysis，MHD)患者矿物质骨代谢异常影响。方法对2014 年7 月至2015 年6 月份在浦南医院血液透析室行维持性血液透析治疗的97 名存在矿物质骨异常的患者，参照中华医学会肾脏病分会2013 年9 年制定的“慢性肾脏病矿物质与骨异常诊治指导”为治疗原则，应用持续质量改进方法，建立持续质量改进团队，把患者及家属纳入治疗管理当中来，通过计划(plan)、实施(do)、检验(check)、应用(act)，等步骤，加强对治疗的干预和监管，观察期12 个月，检测经过持续质量改进后血钙、磷、iPTH 水平及达标率的变化，并与改进前对比。结果经过持续质量改进后，我院MHD 患者钙磷代谢紊乱纠治情况有所改善。血磷平均水平由(2.42±0.76)mmol/L 降至(2.13±0.80)mmol/L(t=2.589，P =0.011)，达标率由24.74%上升到
41.24%(χ2=5.969，P=0.014),有统计学意义；全段甲状旁腺激素(intact parathyroid hormone，iPTH)平均水平由(445.97±407.22)ng/ml 降至(335.21±386.23)ng/ml(t=1.942，P=0.043)，达标率由34.02%上升到48.45%(χ2=3.312，P=0.041),有统计学差异；血钙平均水平由(2.23±0.40)mmol/L 升至(2.24±0.25)mmol/L(t=0.212, P=0.901)，达标率由45.36%上升到56.70%(χ2=2.490，P=0.114)。患者对新治疗手段的接受度有改善，使用非含钙磷结合剂的患者占比增加，由1.03%上升到12.37%(χ2=9.976，P =0.001),有统计学意义；采用组合血液净化手段的患者占比有增加，由36.08%上升到57.73%(χ2=9.168，P=0.002)，有统计学意义；行甲状旁腺切除手术的患者人数2.06%增加到11.34%(χ2=6.678，P =0.001)，有统计学意义；采用活性维生素D 剂的患者人数由64.95%下降到55.67%(χ2=1.744，P = 0.187)。结论持续质量改进的方法可以有效改善维持性血液透析患者的钙磷代谢紊乱。

关键词: 持续质量改进, 慢性肾脏病-矿物质骨异常, 钙磷代谢异常, 高磷血症, 血液透析

Abstract: Objective To investigate the effect of continuous quality improvement (CQI) on bone mineral metabolism in maintenance hemodialysis (MHD) patients. Methods We observed 97 MHD patients with abnormal bone mineral metabolism in our hospital during July 2014 to 2015 June. According to the "Guidance for Diagnosis and Treatment of Mineral and Bone Disorder in Chronic Kidney Disease”issued by Nephrology Association of Chinese Medical Association in September 2013, they were managed with CQI to intensify supervision and intervention of the treatment, to establish continuous quality improvement team, and to attract patients and their families taking part into the administration of treatment through the four steps called PDCA (plan, do, check and act). The observation period lasted 12 months. Changes of serum Ca, P and PTH levels and the compliance rate of serum Ca, P and iPTH were evaluated before and after CQI. Results After CQI, the abnormal calcium and phosphorus metabolism in MHD patients improved in our hospital. Serum phosphorus decreased from 2.42±0.76 mmol/L to 2.13±0.80 mmol/L (t=2.589, P=0.011) with the increase of compliance rate from 24.74% to 41.24% (χ2=5.969, P=0.014); average serum iPTH decreased from 445.97± 407.22ng/ml to 335.21 ± 386.23 ng/ml (t=1.942, P=0.043), with the increase of compliance rate from 34.02% to 48.45% (χ2=3.312，P=0.041); average serum Ca increased from 2.23±0.40 mmol/L to 2.24±0.25 mmol/L (t=0.212, P=0.901) with the increase of compliance rate from 45.36% to 56.70% (χ2=2.490, P= 0.114). In addition, the number of patients accepting new therapeutic measures increased; the number of patients using non-Ca-P binders increased from 1.03% to 12.37% (χ2=9.976, P=0.001); the number of patients used combined blood purification methods from 36.08% to 57.73% (χ2=9.168, P=0.002); the number of patients having parathyroid surgery increased from 2.06% to 11.34% (χ2=6.678, P=0.001); the number of patients using active vitaminD decreased from 64.95% to 55.67% (χ2=1.744, P=0.187). Conclusion Continuous quality improvement can effectively improve the abnormal Ca-P metabolism in MHD patients.

Key words: Continuous Quality Improvement, Chronic Kidney Disease-mineral and Bone Disorder, Abnormal calcium and phosphorus metabolism , Hyperphosphatemia, Hemodialysis