腹透患者营养不良-微炎症状态对腹膜炎及死亡风险的影响

Malnutrition-Inflammation Status Increased the Risk of Peritonitis and Hospitalization/death in Chinese Peritoneal Dialysis Patients

目的：探讨腹膜透析（peritoneal dialysis,PD）患者营养不良-炎症复合体综合征（malnutrition inflammation complex syndrome,MICS）对腹膜炎发生率、住院频率及死亡风险的影响。方法：对符合纳入标准的98例PD患者,采用营养不良-炎症评分（malnutrition inflammation score,MIS）评估MICS,按MIS分值分为轻度（1~8分）、中度（9~18）、重度（〉18）;观察患者人体测量学指标、尿素清除率（KT/V）和标化蛋白分解代谢率（nPCR）,检测生化指标、微炎症指标[超敏C反应蛋白（hs-CRP）、肿瘤坏死因子-α（TNF-α）、白细胞介素-6（IL-6）]、24h腹透液中丢失的蛋白量;随访6个月内患者腹膜炎发生率、住院频率及死亡率,运用多元Logistic回归分析、COX比例风险分析MIS对腹膜炎发生率、住院及死亡风险等预后的影响。结果：所纳入的98例PD患者中,MICS患者56例,占57%,其中MIS轻、中、重度平均分值分别为5、12、19.5（各占53.06%、39.80%、7.14%）;MIS分值越高,患者年龄越大,人体测量学指标包括BMI、MAC和TSF下降,与营养相关的生化指标包括Alb、BUN和Scr水平明显降低（P〈0.05）;炎症因子hs-CRP和IL-6水平明显升高（P〈0.05）,但TNF-α水平在各组间差异无统计学意义。各组KT/V、nPCR和24h腹透液蛋白丢失量差异无统计学意义。MIS与腹膜炎发病频次、住院频次、住院总天数显著正相关（P〈0.01）,MIS每增加1分则患腹膜炎的相对风险为1.185（1.036~1.355P〈0.05）,死亡风险为1.242（1.102~1.401,P〈0.01）。结论：57%的维持性腹膜透析患者可并发MICS;MICS患者具有高龄的特点;MICS可增加PD患者患腹膜炎、住院频次以及死亡风险;MIS可预测患者腹膜炎和死亡风险。

Objective：We investigate the effect of Malnutrition Inflammation Complex Syndrome（MICS）of continuous ambulatory peritoneal dialysis CAPD patients on the morbidity and mortality.Methods：98 chronic stable patients（47 men,51 women;age 59.1±18.0 years）on CAPD in one PD center were studied and followed over 6 months.The baseline MIS at the beginning of the study and the dates of peritonitis and mortality or hospitalization during the study period were obtained.The MIS and Quantitative Subjective Global Assessment（MQSGA）were assessed simultaneously by two trained physician.The anthropometry,inflammation makers and biochemical assays were measured.The relative risk of peritonitis,hospitalization or death was analysis by the logistic regression and Cox Proportional Hazard Model.Results：Results The MICS morbidity was 57.1% in PD,in which the mild 53.1%,moderate 39.8%,and severe 7.14% respectively.A higher MIS score reflects the elder age,a more worse nutritional status which showed a lower body mass index（BMI）,triceps skinfold（TSF）and mid-arm circumference（MAC）;and a lower pre-albumin,albumin concentrations,BUN or Scr.On the other hand,there showed a more severe inflammation status including increased high sensitive-C Reactive Protein and Interleukin-6,but the Tumor Necrosis Factor had no difference.The KT/V、nPCR and protein loss in PD liquid over 24 h had no difference.During the 12-month follow-up,12 patients died and 8 patients left the cohort.The MIS were significant positively correlated to peritonitis,hospitalization days,and frequency of hospitalization.The MIS was the independent risk factor of peritonitis and death.For every unit increased in the MIS score,the adjusted hazard ratio for peritonitis was 1.185（95% confidence interval 1.036～1.335,P0.05）,for the death was 1.242（95% confidence interval 1.102～1.401,P0.01）.Conclusion：The 57.14% PD complicated the MICS which had a elder age,worse malnutrition status,and severe inflammation.MICS increased the risk of peritonitis,frequency of hospitalization,and death events in PD.MIS was independent predictor of peritonitis and death in the multivariate Cox proportional hazard model.For every one unit increased in the MIS,the adjusted hazard ratio for peritonitis was 1.185,for death was 1.242.