血液透析患者死亡原因分析

Analysis of the death causes in patients treated with hemodialysis

目的:分析血液透析(hemodialysis,HD)患者的死亡原因,探讨影响生存的相关危险因素,为提高HD患者生存率提供依据。方法:分析1998-01-01～2008-12-31HD死亡患者的临床资料,分析其死亡原因。结果:同期HD患者共811例,死亡237例,死亡患者透始中位年龄岁67(19～87岁),男性占60.8%,中位生存时间9.6月(0.1～96.6月)。主要死因为心血管疾病(20.3%)、脑血管疾病(16.5%)、感染(24.9%)[与非心脑血管疾病死因患者相比,死于心脑血管疾病的HD患者女性比例(43.7%vs36.7%,P<0.05)、糖尿病肾病的比例(25.0%vs11.1%,P<0.05)、HD前有左室肥厚史的比例(9.6%vs4.7%,P<0.05)、充血性心衰病史的比例(23.3%vs13.4%,P<0.05)较高,体质量指数(BMI)(21.1kg/m2vs23.6kg/m2,P<0.05)、eGFR(7.6ml/min·1.72m2vs10.0ml/min·1.72m2,P<0.05)较低]。Logistic回归分析提示BMI较低、透析前有充血性心衰史和左室肥厚史是HD患者死于心血管疾病的危险因素。与非感染死因患者相比,死于感染的HD患者透始年龄较大(66岁vs62岁,P<0.05)、透析前血白蛋白较低(30.2g/Lvs33.1g/L,P<0.05)。Logistic回归分析提示透始年龄大、透析前低白蛋白是HD患者死于感染的危险因素。33.3%患者于HD开始3月内死亡,其主要死亡原因为感染(38.0%)、心血管疾病(22.8%)、脑血管疾病(11.4%)。HD开始3月内死亡患者的慢性肾小球肾炎比例(20.6%vs36.2%,P<0.05)、透析前血钙(1.91mmol/Lvs2.18mmol/L,P<0.05)、血白蛋白(29.2g/Lvs34.7g/L,P<0.05)、CO2-CP(18.52mmol/Lvs22.15mmol/L,P<0.05)、eGFR(7.55ml/min·1.72m2vs10.29ml/min·1.72m2,P<0.05)均显著较低,HD前有充血性心力衰竭病史的比例(19.4%vs16.3%,P<0.05)、Charlson并发症指数(CCI)=5～10的比例(25.4%vs13.5%,P<0.05)显著较高。Logistic回归分析提示透析前低白蛋白血症、eGFR较低、充血性心力衰竭史、CCI≥5是HD3个月内死亡的危险因素。结论:HD患者主要死亡原因为心、脑血管疾病和感染。在HD开始3月内死亡风险较高,尤其是透析前血白蛋白较低、有充血性心力衰竭病史、CCI≥5和开始透析时机较晚的患者。积极改善患者的营养状况、防治心脑血管疾病、感染等并发症、适时开始HD可能有助于提高患者的早期生存率。

Objective： To analyze the death causes in patients with hemodialysis, explore the risk factors affecting survival and provide some way to improve the survival of hemodialysis patients. Methodology ： The causes of death in patients with hemodialysis were retrospectively analyzed during the periods Jan. 1998 to Dec. 2008. Results：Two hundred and thirty seven cases in total eighty hundred eleven hemodialysis patients were died in the study period. Their average age at the beginning of hemodialysis was 63 （ 19 - 87） years old and men accounted for 60.8%. The median survival time was 9.6 （0. 1 - 96.6） months. The main causes of death in our patients were cardiovascular disease （20.3%） , infection （24.9%） and cerebrovascular disease （ 16.5% ）. [ The proportion of females （43.7% vs 36.7% , P 〈 0.05） and diabetic nephropathy as the underlying disease （25.0% vs 11. 1% , P 〈 0.05 ） was significantly higher and more patients had the history of left ventrieular hypertrophy （ 9.6% vs 4.7% , P 〈 0.05 ） and congestive heart failure （23.3% vs 13.4% , P 〈 0.05 ） before hemodialysis in patients died due to cardiovascular and cerebrovaseular diseases whose BMI （21. 1 vs 23.6 kg/m2 , P 〈 0.05 ） and eGFR （7.6 vs 10.0 ml/min 1.72m2, P 〈 0.05 ） before hemodialysis were lower. Logistic： regression analysis revealed that lower BMI, the history of left ventrieular hypertrophy and congestive heart failure before hemodialysis were the risk factors of dying due to cardiovascular and eerebrovaseular diseases. The patients died from infection were older （ 66 vs 62 years old, P 〈0.05 ） and their blood albumin before hemodialysis was lower （ 30.2 vs 33. 1 g/L, P 〈 0.05 ）. Logistic regression analysis showed that older patients, lower blood albumin before hemodialysis were the risk factors of dying from infection. 33.3 percent of the all deaths died within 3 months of hemodialysis. The main causes of death were infection （ 38.0% ） , cardiovascular diseas e（ 22.8% ） and eerebrovaseular disease （ 11.4% ） in patients died within 3 months of hemodialysis. The proportion of chronic gtomerulonephritis（CGN） as underlying disease was significantly lower （ 20.6% vs 36.2% , P 〈 0.05 ）. More patients had the history of congestive heart failure （ 19.4% vs 16.3% , P 〈 0.05） and Charlson eomorbidity index （CCI） = 5 - 10 before hemodialysis in patients died within 3 months of hemodialysis and their blood calcium（1.91 vs 2. 18 mmol/L, P 〈0. 05）, blood albumin （29. 2 vs 34. 7 g/L, P 〈0. 05） and eGFR （7.55 vs 10. 29 ml/min 1.72m2, P 〈0. 05） before hemodialysis was significantly lower. Logistic regression analysis showed that lower blood albumin, lower eGFR, the history of congestive heart failure and CCI t〉 5 before hemodialysis were the risk factors of dying within 3 months of hemodialysis. Conclusion： Conclusion： Cardiovascular and cerebrovascular diseases, infection are the main causes of death in hemodialysis patients. There is a higher risk d death within 3 months of hemodialysis especially in patients whose blood albumin is lower, CCI i〉5 and who have the history of congestive heart failure before hemodialysis and start hemodialysis late. Improvement of the nutritional status of patients, prevention and treatment of cardiovascular and eerebrovaseular diseases and infection complications of hemodialysis and starting hemodialysis early properly should be emphasized to improve the early smwival of hemodialysis.