小剂量日间非卧床腹膜透析对残肾功能较好的糖尿病终末期肾病患者的疗效

Efficacy of low-dose daytime ambulatory peritoneal dialysis in diabetic end-stage renal disease patients with better residual renal function

目的 研究小剂量日间非卧床腹膜透析（DAPD）和小剂量持续非卧床腹膜透析（CAPD）对残肾功能较好的糖尿病终末期肾病（ESRD）患者的疗效.方法 病情稳定、残肾功能较好（rGFR≥5 ml/min,且尿量≥750 ml/d）的40例糖尿病ESRD患者入选.按数字随机法分为小剂量DAPD组20例和小剂量CAPD组20例.DAPD组透析处方为1.5 L或2 L,3次/d,每次留腹3～4 h,夜间干腹.CAPD组透析处方为1.5～2 L,3次/d,或1.5 L,4次/d,夜间留腹.在研究开始及6个月后,分别计算两组腹膜尿素氮清除率（Kt/V）、残肾Kt/V、每周总Kt/V、Ccr、rGFR等指标;测定24 h尿蛋白量、24 h腹透液蛋白、血清白蛋白、空腹血糖、糖化血红蛋白及胰岛素剂量;用改良主观综合性营养评估法（SGA）评估患者营养状况.结果 共35例患者完成研究.两组患者年龄、性别、体质量指数、透析龄、透析液肌酐/血肌酐（D/Pcr）等基线值差异无统计学意义.6个月后,CAPD组胰岛素剂量和24 h腹透液丢失蛋白明显高于DAPD组,分别为（33.6±10.9）U/d比（20.6±6.2）U/d（P＜0.05）和（11.13±4.95）g比（5.66±2.88）g（P＜0.01）,而血清白蛋白明显低于DAPD组[（29.7±4.2）比（36.5±3.9）g/L,P＜0.05].DAPD组与CAPD组相比,24 h净超滤量为（554±187）ml比（309±177）ml,24 h尿量为（1090±361）ml比（750±258）ml,rGFR为（8.21±2.40）ml/min比（4.88±2.11）ml/min,DAPD组均显著高于CAPD组（均P＜0.05）.结论 对于残肾功能较好的糖尿病ESRD患者,小剂量DAPD较小剂量CAPD能更好地控制血糖,改善营养状态及保护残肾功能.

Objective To study the efficacy of low-dose daytime ambulatory peritoneal dialysis （DAPD） and low-dose CAPD in diabetic end-stage renal disease （ESRD） patients with better residual renal function （RRF）. Methods Forty stable diabetic ESRD patients with better RRF （rGFR ≥ 5 ml/min and urine volume ≥ 750 ml/d） were enrolled. They were randomly divided into two groups： low-dose DAPD group （n=20） and low-dose CAPD group （n=20）. DAPD group received three 1.5 L to 2 L daily exchanges with a nocturnal empty belly, dwelling for 3 to 4 hours. CAPD group received three 1.5 L to 2 L daily exchange or four 1.5 L daily exchange regimens and dwelled during the night. At the beginning of the study and 6 months later, total weekly Kt/V and Ccr （peritoneal＋renal）, rGFR were calculated. Meanwhile 24-hour urinary protein,serum albumin （Alb）, hemoglobin （Hb）, fasting plasma glucose, glycosylated hemoglobin and insulin dosage were measured. Nutritional status was assessed by SGA. Results Thirty-five patients fulfilled the study. There were no significant differences between two groups in age, gender, BMI,PD time, D/Pcr, etc. At the end of the 6th month, the insulin dose[（33.6±10.9） U/d] and 24-hour dialysate protein [（11.13t4.95） g] in CAPD group were significantly higher as compared to DAPD group [（20.6±6.2） U/d, P〈0.05 and （5.66±2.88） g, P〈0.01 respectively]. Alb in CAPD group [（29.7±4.2） g/L] was significantly lower than that in DAPD group [（36.5 ±3.9） g/L, P〈0.05].While the net ultrafiltration [（554±187） ml vs （309±177） ml], 24-hour urine volume [（1090±361）ml vs （750±258） ml] and rGFR [（8.21±2.40） ml/min vs （4.88±2.11） ml/min] in DAPD group were all significantly higher than those in CAPD group （all P〈0.05）. Conclusion For the diabetic ESRD patients with better RRF, the low-dose DAPD regimen is more effective to control plasma glucose, improve nutritional status and protect RRF than the low-dose CAPD.