维持性血液透析患者内瘘血流量与炎性反应状态的关系及对心血管病的影响

Association of arteriovenous fistula blood blow dynamics with inflammation and its effect oncardiovascular diseases in maintenance hemodialysis patients

目的探讨维持性血液透析（MHD）患者内瘘血流量与炎性反应状态的关系及其对心血管病（CVD）的影响。方法30例以自体动静脉内瘘（AVF）为透析通路的MHD患者（MHD组）及12例健康体检者（对照组）入选本研究。TransonicHD02透析监测仪监测内瘘血流量（Qa）和心输出量（CO）。MHD组在监测Qa前取透前血标本，对照组标本来自我院健康体检人群。用免疫透射比浊法检测高敏C反应蛋白（hsCRP）；用流式细胞仪的液相蛋白定量技术检测炎性因子白细胞介素（IL）2、IL．6、IL．10、肿瘤坏死因子（TNF）。随访时间19个月，记录发病情况。结果两组年龄及性别差异无统计学意义。MHD组透前IL-6、IL-10、TNF、hsCRP均显著高于对照组[2．38（1．86-4．69）比1．14（0．27-1．18）ng／L，P〈0．01；1．47（1．19-2．10）比1．04（0．00～1．23）ng／L，P〈0．01；1．33（1．05～1．56）比0．54（0．00～1．24）ng／L，P〈0．05；4．90（1．58～7．45）比1．50（0．63～1．90）mg／L，P=0．011。随访期间，6例（20．0％）患者至少发生1次心血管病。发生心血管病者Qa、IL．6、hsCRP均显著高于未发病者[（1120＋192）比（893＋189）ml／min，P〈O．05；4．86（2．96～7．85）比2．20（1．80～3．10）ng／L，P〈0．01；11．75（3．83～31．53）比4．45（1．05～6．68）mg／L，P〈0．051。二元Logistic回归分析显示，IL-6为CVD的独立危险因素（HR=1．943，95％CI：1．110～3．402，P=0．02）。Spearman相关分析及线性回归分析显示，Qa与IL-6呈正相关（β=0．492，P〈0．01）。路径分析结果显示，Qa通过IL-6对CYD有间接的显著影响。结论IL-6是CVD发生的独立危险因素。Qa与IL．6呈正相关。Qa可通过影响MHD患者IL-6水平参与了CVD的发生。

Objective To examine the association of arteriovenous fistula （AVF） blood flow （Qa） dynamics with inflammation state and its effect on cardiovascular diseases （CVD） in maintenance hemodialysis （MHD） patients. Methods Thirty MHD patients with AVF and twelve healthy people were enrolled in the study. Qa and cardiac output （CO） were measured by Transonic Hemodialysis Monitor HD 02. In MHD patients, pre-dialysis blood samples were taken before Qa monitoring. High-sensitivity C-reactive protein （hsCRP） was measured by immunoturbidimetry（Kyoma, Japan）. Inflammatory factors IL-2, IL-6, IL-10, TNF were measured by Cytometric Bead Array （BDTM）. Cardiovascular diseases morbidity was monitored prospectively within nineteen months follow-up period. Results There were no significant differences in age and sex between MHD patients and healthy people. The serum IL-6, IL-10, TNF and hsCRP were significantly higher in MHD patients than those in healthy controls [2.38 （1.86-4.69） vs 1.14 （0.27-1.18） ng/L, P〈0.01; 1.47 （1.19-2.10） vs 1.04 （0.00-1.23） ng/L, P〈0.01; 1.33 （1.05-1.56） vs 0.54 （0.00- 1.24） ng/L, P〈0.05; 4.90 （1.58-7.45） vs 1.50 （0.63-1.90） mg/L, P=0.01]. During the follow-up period, 6 patients （20.0%） developed at least one episode of cardiovascular event. Qa, serum IL-6 and hsCRP levels were significantly higher in patients with CVD as compared to those without CVD [（1120＋192） vs （893＋189） ml/min, P〈0.05; 4.86 （2.96-7.85） vs 2.20 （1.80-3.10） ng/L, P〈 0.01;11.75 （3.83-31.53） vs 4.45 （1.05-6.68） mg/L, P〈0.05]. Binary Logistic regression analysis demonstrated that serum IL-6 was an independent and stronger risk factor for CVD morbidity [HR= 1.943, 95%CI （1.110-3.402）, P=0.02]. Spearman rank correlation analysis and liner regression analysis showed that Qa was positively correlated with serum IL-6 ~=0.492, P〈0.01）. Path analysis suggested that Qa contributed to CVD mortality via the increase of serum IL-6. Conclusions AVF blood flow monitoring is important for MHD patients. IL-6 is an independent risk factor of CVD in MHD patients. AVF blood flow increases cardiovascular diseases morbidity in MHD patients via its promotion of IL-6 production.