血液透析联合血液透析滤过对糖尿病肾病维持性血液透析患者的心脏结构及功能影响

Impact of Hemodialysis Combined with Hemodiafiltration on Cardiac Structure and Function in Maintenance Hemodialysis Patients with Diabetic Nephropathy

目的:探讨血液透析联合血液透析滤过对糖尿病肾病MHD患者心脏结构及功能的影响。方法:选择上海市第六人民医院血液透析中心接受规律血液透析3年以上的糖尿病肾病MHD患者47例,分为单纯HD组17例,常规血液透析3次/周;HD+HDF组30例,常规血液透析2次/周,血液透析滤过1次/周。并收集临床一般资料和生化指标。所有患者在治疗前及治疗3年后均行心脏彩超检查测定左心室舒张末期内径(LVDd)、左心室收缩末期内径(LVDs)、左心房内径(LAD)、左心室后壁厚度(LVPWT)、室间隔厚度(IVST)、左心室射血分数(LVEF)、二尖瓣前向血流E峰与A峰比值(E/A),根据Devereux公式计算左心室心肌质量指数(LVMI)。结果:(1)比较治疗前后P3-、Ca2+×P3-、hs-CRP及Pro-BNP发现,治疗后显著高于治疗前,且与心脏结构和功能密切相关,尤其是与LVMI呈正相关,与LVEF呈负相关,同时与LVEDd、LVEDs、LAD、LVPWT、IVST及E/A存在相关。(2)与同组治疗前比较,HD+HDF组P3-、Ca2+×P3-、Hs-CRP及Pro-BNP均显著低于治疗前,而单纯HD组与之相反,差异均有统计学意义;同时还发现,HD+HDF组LVMI较治疗前下降,LVEF较治疗前升高,差异有统计学意义,而HD组LVMI及LVEF治疗前后均没有变化,差异无统计学意义。(3)两组治疗后比较发现,HD+HDF组P3-、Ca2+×P3-、Hs-CRP及Pro-BNP均显著低于单纯HD组,差异均有统计学意义;HD+HDF组LVEDd及LVMI显著低于单纯HD组,而LVEF显著高于单纯HD组,差异也有统计学意义。结论:血液透析联合血液透析滤过能有效改善糖尿病肾病MHD患者的左心室肥大及心功能,这可能与血液透析滤过能更好的纠正钙磷代谢紊乱、减轻炎症反应及降低Pro-BNP有关。

Objective：Objective analysis Impact of hemodialysis combined with hemodiafiltration on cardiac structure and function in maintenance hemodialysis patients with diabetic nephropathy. Methods：47 MHD patients with diabetic nephropathy are from Nephropathy Center and have acccepted maintenance hemodialysis at last 3 year, they were divided into standard HD group 17 cases, conventional hemodialysis 3 times per week; HD ＋ HDF group 30 cases, conventional hemodialysis 2 times per week, hemodi- alysis 1 times per week. and other correlated parameters were also measured. The left ventricular end -diastolic diameter（ LVDd）, left ventricular end - systolic diameter（ LVDs ）, left atrial diameter（ LAD）, left ventricular posterior wall thickness （ LVPWT）, inter- ventricular septal thickness（IVST） , Left ventricular ejection fraction（LVEF） , rote of E/A were detected by ultrasonic cardiography Before treatment and after 3 years of treatment, and it calculated the left ventricular mass index （LVMI） according to the Devereux formula. Results： （ 1 ） Phosphorus, calcium - phosphorus product, high sensitiving C - reactive protein and Pro - BNP were increased in compared with before treatment, and the closely related with cardiac structure and function, especially were positively correlated with the left ventricular mass index and negatively correlated with Left ventrieular ejection fraction; On the other hand, Phosphorus, calcium - phosphorus product, high sensitiving C - reactive protein and Pro - BNP were also correlated with LVEDd, LVEDs, LAD, LVPWT,IVST and E/A, the disorders of calcium - phosphorus metabolism, micro inflammatory state and higher Pro - BNP were closely related with cardiac structure and function in MHD patients with diabetic nephropathy. （2）Compared with the same group be-fore treatment, p3 - , Ca2 ＋ x p3 - , ns - CRP and Pro - BNP were lower than those before treatment in the HD ＋ HDF group, and the standard HD group on the contrary, the differences were statistically significant; It is also found that LVMI decreased and LVEF in- creased compared with before treatment in the HD ＋ HDF group the difference was statistically significant, while the standard HDgroup before and after treatment, LVMI and LVEF had no change, it＇ s no statistically significant differences. （ 3 ） According to the two groups after treatment comparision, ti＇ s found that in the HD ＋ HDF group p3- , Ca2 ~ ~ p3 - , Hs - CRP and Pro - BNP were sig- nificantly lower than those of the standard HD group, the difference had statistical significance; in the HD ＋ HDF group, LVEDd and LVMI were significantly lower than those of the standard HD group, but LVEF was significantly higher than that in the standard HD group, there were aslo statistically significant differences. Conclusion： Hemodialysis combined with hemodiafiltration can be improving left ventricular hypertrophy and cardiac function in maintenance hemodialysis patients with diabetic nephropathy, it may be that hemo diafiltration is better than hemodialysis in correcting calcium and phosphorus metabolism, reducing the inflammatory reaction and de creasing Pro - BNP.