血液灌流对老年血液透析患者不安腿综合征和睡眠质量的影响

The influence of hemoperfusion on restless legs syndrome and sleep quality in elderly maintenance hemodialysis patients

目的了解老年维持性血液透析（maintenance hemodialysis，MHD）患者不安腿综合征（rest lesslegs syndrome，RLS）的患病率、危险因素及其对睡眠质量的影响，观察血液灌流改善对老年血液透析患者不安腿症状和睡眠质量的有效性和安全性。方法以118例因慢性肾衰竭进行MHD治疗的老年患者为研究对象，不安腿综合征的诊断采用国际不安腿综合征研究小组制定的诊断标准量表，以匹兹堡睡眠质量指数（Pittsburgh sleep quaiity index，PSQI）进行睡眠质量评估。对伴有RLS老年MHD患者进行血液灌流治疗，疗程3个月，观察治疗前后患者RLS症状和PSQI评分情况及不良反应。收集患者的临床和生化资料，进行t检验或X^2检验，部分指标间进行相关分析和Logistic回归分析。结果（1）118例老年血液透析患者中，并存RLS者31例，患病率为26．3％，其中男性11例，女性20例；（2）RLS组患者透析龄（t=2．332，P=0．021）、性别比（女／男）（X^2=15．343，p=0．000）、血磷（t=4．784，P=0．000）、β2-微球蛋白（t=13．124，P=0．000）和甲状旁腺激素水平（t=10.900，P=0．000）明显高于非RLS组，差异均有统计学意义。而在年龄（t=0．341，P=0．734）、干体质量（t=0．008，P=0．994）、透析器膜材料（X^2=1．055，P=0．304）、血肌酐（t=0．051，P=0．960）、血尿素（t=0．899，P=0．370）、血红蛋白（t=0．912，P=0．364）、红细胞压积（t=0．601，P=0．549）、血钙（t=0．192，P=0．124）、铁蛋白（t=0．200，P=0．842）、转铁蛋白饱和度（t=1．094，P=0．276）等生化指标方面，两组差异均无统计学意义；Logistic回归分析结果显示，血甲状旁腺激素和血β2-微球蛋白是老年MHD患者并发RLS的独立危险因素；（3）RLS组PSQI明显高于非RLS组，分别为10．7±2．7和4．9±2．5（t=10．948，P=0．000）；睡眠差主要表现在主观睡眠质量、睡眠时间、习惯睡眠效应、日间功能等方面，且RLS严重程度与PSQI总分呈正相关（r=0．839，P〈0．05）；（4）经血液灌流治疗后，RLS患者血磷、血甲状旁腺激素、血β2-微球蛋白、RLS和PSQI评分均明显下降，与治疗前比较，差异有统计学意义；（5）患者在治疗过程中生命体征平稳，无不良反应发生。结论老年MHD患者RLS的患病率较高，且普遍存在睡眠质量差等问题；血甲状旁腺激素和β2-微球蛋白是老年MHD患者并发RLS的独立危险因素，血液灌流能改善老年MHD患者的RLS和睡眠质量，且安全性好。

Objective To explore the prevalence and influencing factors of restless legs syndrome （RLS） in elderly maintenance hemodialysis （MHD） patients, to analyze the relationship between RLS and sleep quality, and to observe the efficacy and safety of hemoperfusion in improving RLS and sleep quality in elderly MHD patients with RLS. Methods A total of 118 cases with maintenance hemodialysis were involved in this study. The RLS was diagnosed according to the criteria of the International Restless Legs Syndrome Study Group （IRLSSG）. The subjects＇ quality of sleep was assessed by the Pittsburgh Sleep Quality Index （PSQI）. The elderly MHD patients with RLS received hemoperfusion once a week for 3 months. The clinical and biochemical indexes were collected including age, gender, duration of hemodialysis, pre-dialysis blood concentrations of creatinine, hemoglobin, parathyroid hormone, β2- microglobulin, etc. T test,X^2 test and binary logistic regression analysis were performed. Results RLS prevalence was found in 26.27% （11 men, 20 women, the ratio was 0.55 ： 1） of 118 elderly MHD patients. The duration of hemodialysis, sex ratio （female/male）, the level of serum phosphorus, 132-microglobulin and parathyroid hormone in elderly MHD patients with RLS were significantly higher than those in elderly MHD patients without RLS （t=2.332,X^2=15.343,t=4.784,13.124,10.900;all P〈0.05）. And there were no significant differences in age, dry weight, material of dialyzer membrane, and levels of serum creatinine, urea nitrogen, hemoglobin, hematocrit, calcium, ferritin and transferrin saturation between patients with RLS and without RLS（t= 0. 341,0. 008,1. 055,0. 051,0. 899,0. 912,0. 601,0. 192,0. 200,1. 094;all P〉0.05）. Logistic regression analysis revealed that serum parathyroid hormone and β2-microglobulin were the important risk factors for RLS in elderly MHD patients. PSQI was higher in RLS group than in non-RLS group[（10. 7±2. 7） vs. （4.9±2.5）, t=10.948,P=0. O00]. The manifestations of poor sleep were poor indexes of subjective sleep quality, sleep duration, habitual sleep efficiency and daytime dysfunction in MHD patients with RI.S. And the RLS severity was correlated with PSQI （r= 0. 839,P〈0. 05）. After the treatment with hemoperfusion, the level of serum phosphorus, serum parathyroid hormone, serum β2-microglobulin, RLS severity score and PSQI were significantly decreased in RLS patients compared with pre-hemoperfusion. The vital sign of RLS patients were stable during hemoperfusion, and there were no adverse events after the treatment with hemoperfusion. Conclusions The prevalence of RLS is high, and poor sleep quality is found in elderly MHD patients with RLS. Serum parathyroid hormone and β2-microglobulin are the important risk factors for RLS in elderly MHD patients. Hemoperfusion can effectively improve the RLS and sleep quality and is well tolerated.