透析患者下肢动脉闭塞症的危险因素分析

Analysis of risk factors of peripheral arterial occlusive disease in dialysis patients

目的观察终末期肾病（ESRD）维持性血液透析和腹膜透析患者下肢动脉闭塞症的发病情况，并探讨该病在ESRD患者中的相关危险因素。方法用自动化外周动脉硬化检测仪（VP1000，日本Colin）测定臂踝脉搏波传导速度（baPWV）及臂踝血压比（ABPI）。受检对象为北京协和医院肾内科血液净化中心150例规律透析时间超过3个月的ESRD患者，其中95例为血液透析患者（HD组），55例为持续非卧床腹膜透析患者（CAPD组），对照组为同期在肾内科门诊随诊的50例慢性肾脏病（CKDⅡ-Ⅲ期）患者。收集患者一般资料及常规生化指标。评价透析充分性和营养状况。ELISA法测定血C反应蛋白（CRP）和甲状旁腺激素（iPTH）。ABPI〈0．9的患者同时行下肢动脉彩色多普勒检查，部分患者进行了CT血管造影（CTA）检查。用SPSS12．0软件包进行独立样本t检验、相关性分析和多元回归分析。结果（1）ESRD患者下肢动脉闭塞症（ABPI〈0．9）的发生率显著高于CKD组（11．33％比0，P=0．016），且CAPD组发生率显著高于HD组（20．0％比6．3％，P=0．011）。随后的血管彩超和CTA证实股浅动脉和胫前、后动脉是血管狭窄和闭塞的好发部位。出现间歇性跛行的患者比例为23．1％。（2）相关分析表明，ESRD患者ABPI与透析方式（，=6．491，P=0．011）、年龄（r=-0．338，P=0．000）、总胆固醇（TC）（r=-0．185，P=0．028）、高密度脂蛋白（HDL）（r=0．179，P=0．035）、Scr（r=0．244，P=0．003）、BUN（r=0．281，P=0．001）、Kt／V（r=-0．275．P=0．001）、标准化蛋白分解代谢率（nPCR）（r=O．269，P=0．001）、上肢平均舒张压（DBP）（r=0．267，P=0．001）、平均动脉压（MAP）（r=0．225，P=0．006）、下肢收缩压（SBP）（r=0．593，P=0．000）、下肢DBP（r=0．215，P=0．009）、PWV（r=0．202，P=0．014）呈正或负相关。（3）多元回归分析表明，透析方式、HDL、Alb、MAP、上肢DBP、下肢SBP和baPWV是ABPI的独立危险因素。结论ESRD患者下肢动脉闭塞症的发生率显著高于非透析的CKD患者。ABPI是较好的筛查方法。营养不良、脂代谢紊乱、高血压以及动脉硬化是ESRD患者出现下肢动脉阻塞的危险因素。

Objective To investigate the morbidity of peripheral arterial occlusive disease （PAOD） in dialysis patients and the associated risk factors of PAOD. Methods Two hundred patients including 95 on hemodialysis, 55 on peritoneal dialysis and 50 with stage 2-3chronic kidney disease （CKD） in Peking Union Medical College Hospital were enrolled in this study. Brachial-ankle pulse wave velocity （baPWV） and ankle-brachial BP index （ABPI） were detected by device （VP1000, Japan Colin）. Clinical data of these patients were collected. Plasma CRP, Scr, BUN, Hb, Ca, P, iPTH, Alb, Palb, Cho, TG, LDL, HDL were measured. Lower extremity arteries uhrasonography and CT angiography （CTA） were performed in the patients with ABPI〈0.9. Results （1） The morbidity of PAOD （ABPI〈0.9）was significantly higher in dialysis patients as compared to CKD patients （11.33% vs 0, P=0.016）, and was also significantly higher in CAPD patients as compared to HD patients （20.0% vs 6.3%, P=0.011）. Superficial femoral artery, anterior tibia1 artery and posterior tibial artery were common occlusive sites. 23.1% patients complained the intermittent claudications. （2） Correlation analysis revealed that ABPI was associated with dialysis mode if2= 6.491, P=0.011 ）, age （r =-0.338, P= 0.000）, TC （r =-0.185, P= 0.028）, HDL （r=0.179, P=0.035）, Scr （r=0.244, P=0.003）, BUN （r=0.280, P= 0.001）, Kt/V （r=-0.275, P=0.001）, nPCR （r=0.269, P=0.001）, DBP of upper limb （r=0.267, P=0.001）, MAP （r=0.225, P=0.006）, SBP of lower limb （r=0.593, P=0.000）, DBP of lower limb （r=0.215, P= 0.009）, PWV （r=0.202, P=0.014）. （3） Multiple linear regression revealed that dialysis mode, HDL, Alb, DBP of upper limb, SBP of lower limb and baPWV were independent risk factors of ABPI. Conclusions The morbidity of PAOD in dialysis patients is significantly higher than that in CKD patients. Malnutrition, dyslipidemia, hypertension and arterial stiffness are independent risk factors of PAOD in dialysis patients.