血液透析提早干预糖尿病肾病的临床研究

Clinical research of early hemodialysis intervention in the patients with diabetic nephropathy

目的探讨性将糖尿病肾病患者提早进入治疗血液透析,观察对心脑血管事件发生及生存质量产生的影响。方法选2005-03～2009-03在广西血液净化中心治疗的糖尿病肾病患者68例(肌酐清除率(Ccr)≤30 ml/min,但≥15 ml/min,出现水肿,血压、血糖控制良好),随机分为观察组33例,入组后,立即进入血液透析治疗,每周3次,每次治疗时间4.5 h,维持2年;对照组35例,入选后给按肾衰一体化予保守治疗,等待至Ccr下降达到≤15 ml/min才开始进入血液透析治疗,每周3次,每次治疗时间4.5 h,维持2年。观察并记录两组患者从入组至血液透析2年后,心脑血管事件即:心力衰竭、心绞痛、心肌梗死、心脏猝死、恶性心律失常、脑血管病变及高血压的发生发展情况。结果观察组心脑血管事件及高血压的发生率显著低于对照组(P<0.01),两组同一患者在发生2种以上的心脑血管事件及先后累计发生4例次以上心脑血管事件的比较差异有统计学意义(P<0.05),主要的心血管事件为心力衰竭,其次为缺血性心脏病;两组病死率差异无统计学意义(P>0.05);两组入组与研究结束时的肾功能、血清白蛋白(ALB)差异有统计学意义(P<0.01),血糖差异则无统计学意义(P>0.05),而对照组中,进入透析时的ALB与刚入组时及透析2年后相比较,差异均有统计学意义(P<0.01);两组研究结束时的肾功能、ALB、血糖差异无统计学意义(P>0.05)。结论对于出现水肿的糖尿病肾病患者,一旦Ccr≤30 ml/min,主动地提前干预性进入规律血液透析,能够有效降低糖尿病肾病的心脑血管事件的发生率,提高生存质量;提早进入血液透析,虽然不能延缓肾功能损害的进展,但能显著改善低蛋白血症的状况。

Objective To investigate the impact of early hemodialysis on cardio-cerebral vascular events,the quality of life in the patients with diabetic nephropathy. Methods Sixty-elght patients with diabetic nephropathy trea- ted in the center of blood purification of Guangxi in the period of March 2005 to March 2009, with edema, blood pressure and blood glucose under good control, ereatinine clearance rate （Cer） with a range of 15ml/min to 30ml/ min）, were randomly divided into 2 groups, thirty-three patients of the observation group were treated immediately by hemodialysis for 4. 5 hours each time, three times a week, maintained for 2 years ; thirty-five patients of the control group treated with conservative treatment begin to enter hemodialysis until the Ccr decline to below 15ml/min. Hemo- dialysis were performed for 4. 5 hours each time, three times a week, maintained for 2 years. The cardiovascular and cerebrovascular events of two groups were observed from beginning of entering group to the end of 2 years of hemodial- ysis, included the occurrence and development of heart failure, angina, myocardial infarction, sudden cardiac death, malignant arrhythmia, cerebral vascular disease and hypertension. Results The cardio-cerebral vascular events and the occurrence of hypertension in the observation group were significantly lower than those in the control group （P 〈 0. 01 ）. There were a significant difference in the incidence of more than two kinds of cardio-eerehral vascular events and accumulated more than 4 times in the same patient of the two groups （ P 〈 0. 05 ） ; Heart failure is the major cardiovaseular events, followed by ischemie heart disease; There was no significant difference in mortality in the two groups （ P 〉 0. 05 ） ;There were a significant difference in renal function and serum albumin （ALB） in the two groups before and after treatment （ P 〈 0. 01 ）, but blood glucose had no significant difference （ P 〉 0. 05 ）. While in the control group, the ALB at the beginning of entering into hemodialysis was significantly lower than both of at the time that patients entaned into the group and 2 years after hemodialysis （P 〈 0. 01 ） ; There were no significant difference in renal function, ALB and blood glucose in the two groups at the end of the study （P 〉 0. 05）. Conclusion For the diabetic nephropathy patients with edema complication, as soon as Ccr ~〈 30 ml/min, they should be intervened in advance by the maintenance of hemodialysis which can effectively reduce the incidence of cardio-cerebral vascular e- vents and improve quality of life of diabetic nephropathy patients; Although early hemodialysis could not delay the progress of renal damage, but it can significantly improve the situation of hypoproteinemia.