低钙腹透液对CAPD患者主动脉顺应性影响的临床研究

The study on the effect of low calcium dialysate on arterial compliance in CAPD patients

目的:观察低钙透析液(生理钙)对持续非卧床腹膜透析(Continuous ambulatory peritoneal dialysis,CAPD)伴正常或高血钙患者的钙磷代谢和主动脉顺应性的影响,为寻求较适宜的治疗方案提供临床依据。方法:选择校正的血清总钙>2.12mmol/L、全段甲状旁腺素(Intact parathyroid hormone,iPTH)<150pg/ml规律性随访的CAPD患者31例,由标准钙透析液加口服碳酸钙(2.56±0.51)g/d改为用低钙腹透液(百特PD4,Ca1.25mmol/L,其余成分相同)加口服碳酸钙3g/d。使用低钙透析液期间的第0、4、8、12周分别检测血常规、肝功、肾功生化、血脂、C反应蛋白、血iPTH等实验室指标。采用与心电图同步的彩色多普勒超声仪测量主动脉收缩末期内径(Artery systaltic diameter,ASD)、主动脉舒张末期内径(Artery diastolic diameter,ADD),结合脉压差通过公式计算出主动脉顺应分数(Arterial compliance index,ACI)。采用COLINVP-1000型动脉硬化检测仪分别检测患者双侧上臂脚踝间脉搏波传导速度(Brachial-ankle pulse wave velocity,baPWV)和踝臂指数(Ankle-brachial index,ABI)。结果:在改用低钙透析液随访期间,血钙值在第4周后就有明显下降(P<0.05),但仍基本维持在正常水平。血磷值在第12周时才有明显下降(P<0.05)。钙磷乘积第4周后即有明显下降(P<0.05)。iPTH值在第4周后有明显升高(P<0.05),之后基本稳定,无进一步升高。而血清白蛋白、碱性磷酸酶、钠、钾、肌酐、尿素氮、血脂、C反应蛋白等指标差异无统计学意义。第8周后ACI和baPWV的变化有明显改善(P<0.05)但ABI无明显变化。相关性分析发现,同时间点比较(第8、12周)血钙变化与ACI的变化呈负相关(r=-0.44,r=-0.38;P<0.05),与baPWV的变化呈正相关(r=0.48,r=0.43;P<0.05)。第12周,钙磷乘积和血磷的变化与ACI的变化呈负相关(r=-0.47,P<0.05;r=-0.52,P<0.05),其余临床、实验室检测指标的变化与动脉顺应性检查指标之间均不存在相关性(P>0.05)。结论:低钙腹透液配合口服含钙磷结合剂有助于高血钙或正常血钙的腹膜透析患者的主动脉顺应性的好转。而这一作用可能与低钙透析液改善了这部分腹膜透析患者钙磷代谢和钙负荷过重的情况有关。

Objective： To investigate the effect of low calcium dialysate on calcium and phosphorus metabolism and arterial compliance in continuous ambulatory peritoneal dialysis （CAPD） patients with high or normal serum calcium, and provide a optimal treatment for those patients. Methods： Thirty-one CAPD patients （standard cacium dialysate, calcium carbonate intake （2.56 ~ 0.51 ）g/d with high or normal serum calcium （corrective serum calcium 〉2.12 mmol/L,iPTH〈150 pg/ml） were selected in this study.Standard calcium dialysate solution （ 1.75 mmol/L） was changed to lower calcium dialysate （Baxter PD4 with calcium concentration 1.25 mmol/L）.Calcium carbonate （3 g/d ） was used at the meantime.The serum levels of calcium,phosphorus,albumin,alkaline phosphatease,natrium,creatinine （Scr）,blood urea nitrogen （BUN）, hemachrome, TC, TG, LDL, C-Reactive protein （CRP）, intact parathyroid hormone （ iPTH ） were detected periodically at 0,4 th, 8 th, 12 th week.The arterial compliance were echocardiographically examined at the same time.baPWV and ABI were measured by the VP- 1000 automatic ateriosclerosis measurement system.Results ： After changing to PD4, serum calcium, phosphorus concentration and calcium phosphorus product decreased, serum iPTH increased significantly but maintained an acceptable level afterwards.The changes in ACI and baPWV were statistically significant after 8th week. The changes in serum calcium （8 th, 12 th week） was a variable correlating with the simultaneous changes of ACI （r=-0.44,r=-0.38 ; P〈0.05 ） and baPWV（r=0.48, r=0.43 ;P〈0.05 ）.The changes in serum calcium phosphorus product （12th week） and serum phosphorus （ 12 th week） were also variables correlating with the simultaneous changes of ACI （r=-0.47,P〈0.05 ; r=-0.52,P〈0.05）.Conclusion：There were favorable changes in serum calcium,phosphorus and calcium phosphorus product in CAPD patients with high or normal serum cacium after treatment with low calcium dialysate and adequate calcium carbonate intake. As a result,the arterial compliance were improved in those patients.