间断血液透析滤过对尿毒症患者血管内皮细胞功能的影响

Effect of intermittent hemodiafiltration on vascular endothelial function and prognosis in patients with end stage renal disease

目的探讨血液透析间断联合血液透析滤过对终末期肾病(end stage renal disease,ESRD)患者血管内皮功能及预后的影响。方法 ESRD患者按标准入选60例,随机分为血液透析组(HD组,n=30)和血液透析联合血液透析滤过组(HD/HDF组,n=30)。选择10例健康人作为正常对照。彩色超声检测肱动脉血管舒张功能;并检测血清C反应蛋白(C-reactive protein,CRP)、肿瘤坏死因子(tumor necrosis factorα,TNFa)α、可溶性细胞间黏附分子-1(soluble intercellular adhesion molecule-1,sICAM)变化。同时观察2年内患者心脑血管疾病及病死率发生情况。结果①2组患者内皮依赖性舒张功能(endothelium dependent dilation,EDD)、非内皮依赖性舒张功能(endothelium independent dilation,EID)、反应性充血血流量及含服用硝酸甘油后血流量低于正常对照组者,血清CRP、TNFα、sICAM-l水平高于正常对照组,差异有统计学意义(均P<0.05);2组患者间治疗前上述各项指标差异均无统计学意义(均P>0.05)。②2组患者随治疗时间的延长,EDD、EID、反应性充血血流量、含服硝酸甘油后血流量均逐渐降低,差异有统计学意义(均P<0.05),但HD/HDF组治疗后与HD组相同时间点比较,EDD、EID、反应性充血血流量、含服硝酸甘油血流量均高,sICAM-1低,差异有统计学意义(均P<0.05)。③HD组心脑血管疾病发生率高于HD/HDF组,差异有统计学意义(χ2=6.239,P=0.012),HD与HD/HDF2组病死率分别为16.7%、3.3%,差异无统计学意义(χ2=3.208,P=0.073)。结论 ESRD患者血管内皮功能紊乱;间断血液透析滤过能改善血管内皮功能,对减少ESRD患者心脑血管疾病的发生可能有一定的作用。

Objective To investigate the effect of hemodialysis intermittently combined with hemodiafiltration on vascular endothelial function and prognosis in patients with end stage renal disease.Methods Sixty patients with end stage renal disease were randomly divided into hemodialysis group （HD group,n=30） and hemodialysis/hemodiafiltration group （HD/HDF group,n=30）.Ten healthy people were recruited as control group.Endothelium dependent dilation （EDD） and endothelium independent dilation （EID） of brachial artery were determined by non-invasive high resolution color Doppler ultrasonography.Serum levels of C-reactive protein （CRP）,tumor necrosis factor α（TNF-α and soluble intercellular adhesion molecule-1 （sICAM-l） were also determined.During the two years of observation,mortality and the incidence of cardiovascular disease in the two groups were recorded.Results （a） Compared with control group,EDD,EID,blood flow of responsive hyperemia,and blood flow in brachial artery after sublingual nitroglycerin medication decreased significantly in the two patient groups.Serum levels of CRP,TNF-α and sICAM-l were significantly higher in the two patient groups than in control group.Before treatment,there were no differences in EDD,EID,blood flow of responsive hyperemia,blood flow in brachial artery after sublingual nitroglycerin medication,and the levels of CRP,TNF-α and sICAM-l between the two patient groups.（b） EDD,EID,blood flow of responsive hyperemia,and blood flow in brachial artery after sublingual nitroglycerin medication decreased gradually along with the treatment time.EDD,EID,blood flow of responsive hyperemia,and blood flow in brachial artery after sublingual nitroglycerin medication were significantly higher in HD/HDF group than in HD group,and sICAM-l was significantly lower in HD/HDF group than in HD group compared at the same time points.（c） The incidence of cardiovascular disease was higher in HD group than in HD/HDF group.The mortality was 16.7% and 3.3% in HD and HD/HDF groups,respectively,but without statistical significance.Conclusion Vascular endothelial function is deranged in patients with end stage renal disease.Intermittent hemodiafiltration can effectively alleviate the damage of vascular endothelial function,and decrease the incidence of cardiovascular disease in chronic hemodialysis patients.