静脉补铁对维持性血液透析患者微炎症状态的影响

Intravenous iron supplementation links to inflammation in maintenance hemoclialysis patients

目的 探讨不同方式补充铁剂对维持性血液透析（MHD）患者微炎症状态的影响。方法 选择MHD患者71例，随机分为未补铁组（I组，20例）、口服补铁组（Ⅱ组，27例）、静脉补铁组（Ⅲ组，24例），观察用药前后血红蛋白（Hb）、红细胞压积（Hct）、血清铁（SI）、血清铁蛋白（SF）、转铁蛋白饱和度（TSAT）以及血清C反应蛋白（CRP）、白介素-1β（IL-1β）、白介素-6（IL-6）、白介素-10（IL-10）、肿瘤坏死因子-α（TNF-α）等炎症指标的变化，并对不良反应进行监测。另设健康对照组（20例），检测其研究开始时相应的炎症指标。结果 ①纠正贫血的疗效：治疗8周后，Ⅲ组Hb水平较治疗前明显改善（P〈0．01），与I、Ⅱ组比较均明显升高（P〈0．01）；Ⅱ组Hb水平较治疗前明显改善（P〈0．05）；I组Hb水平较治疗前有改善，但差异无统计学意义（P〉0．05）；②纠正缺铁的疗效：治疗8周后，Ⅲ组SF较治疗前显著升高（P〈0．01），与I、Ⅱ组比较，差异均有统计学意义（P〈0．01）；I、Ⅱ组治疗前后SF与TSAT水平比较，均无统计学意义（P〉0．05），I、Ⅱ组之间比较，差异无统计学意义（P〉0．05）；③对炎症指标的影响：MHD患者血清CRP、IL-1β、IL-6、TNF-α等指标均高于健康对照组（P〈0．01或P〈0．05）；IL-10虽高于健康对照组，但无统计学意义。治疗8周后，Ⅲ组血清CRP、IL-1β、TNF-α均较治疗前显著升高（P〈0．01或P〈0．05）；而I、Ⅱ组各项炎症指标较治疗前无明显改变。结论 MHD患者体内均存在不同程度的微炎症状态。静脉补铁可有效改善患者贫血及缺铁，但也加剧了患者体内的微炎症状态。

Objective To investigate the levels of biomarkers of inflammation in patients undergoing maintenance hemodialysis （MHD） and observe how they changed in intravenous, oral, and noniron therapy. Methods 71 MHD patients were enrolled whose hematocrit（Hct） was less than 27% and tranferrin saturation（TAST） was less than 25% and randomly divided into intravenous iron group （n = 24） and oral iron group （n = 27） and non-iron group （n = 20）. Patients who received iron dextran were administered 100 mg as a slow IV injection. A total of 1000 mg was administered over ten sequential dialysis sessions. Patients in the oral group took 600 mg ferrous succinate daily for 8 weeks. Iron is strictly prohibited in the non-iron group. Their Hct, hemoglobin（Hb）, serum iron（SI）, serum ferritin（SF）, TAST and their biomarkers of inflammation were measured at the begin and the end of the study. Biomarkers of inflammation include serum C-reactive protein（CRP）, interleukin-1β（IL-1β）, interleukin-6（IL-6）, interleukin-10 （IL-10） and tumor necrosis factor-α（TNF-α）. 20 healthy volunteers were involved in this study as normal controls. Results At baseline, CRP, IL-1β, IL-6, and TNF-α levels were significantly higher in MHD patients compared with healthy subjects （P〈0. 01 or P 〈0. 05） ; IL-10 levels were numerically higher in the MHD population compared with the healthy population, but the difference did not reach statistical significance. After the eight-week observation period, hemoglobin and serum ferritin were significantly higher in intravenous group than those in oral group and non-iron group. At the end of the trial , biomarkers of inflammation（CRP, IL-β, TNF-α） were significantly elevated in intravenous group （P〈0. 01 or P〈0. 05）. Conclusions Erythropoietin （EPO） therapy and intravenous iron administration are important aspects for managing the anemia of MHD patients, parenteral iron supplementation also induces increased inflammation which is often already present in patients with chronic renal disease and in patients with ESRD undergoing hemodialysis.