维持性血液透析患者血红蛋白的变异性和死亡相关

Hemoglobin variability is associated with mortality in patients on maintenance hemodialysis

目的 探讨维持性血液透析（maintenance hemodialysis,MHD）患者血红蛋白变异性和全因死亡之间的关系. 方法 收集2007年7月至2012年12月上海市透析登记系统中登记的364例上海交通大学医学院附属仁济医院MHD患者一般情况、生化指标以及预后.评估血红蛋白的变异性[血红蛋白标准差（SD）、变异系数（CV）]与全因死亡之间的关系.结果 364例患者平均年龄63.07±13.93岁,平均透析龄76.0 （42.25,134.0）月,死亡患者85例占23.4％.MHD死亡患者平均血红蛋白SD和CV较高[分别为19.19±6.31比13.74±5.89和0.172±0.07比0.126±0.056,P均＜0.001],与存活患者相比均有统计学差异.血红蛋白SD大于P75（上四分位数）组,其发生全因死亡的危险显著高于SD小于P25（上四分位数）组患者[OR=5.964,95％ CI（2.663～13.357）,P＜0.001].校正了年龄、性别、生活方式和生化指标后,两者结果相同[OR=4.961,95％ CI （1.959～11.238）,P＜0.001].Kaplan-Meier分析显示血红蛋白SD和CV小于P25患者其生存率显著低于P75组患者（P均＜0.001）.ROC曲线下面积（AUC）显示血红蛋白SD、CV预测MHD患者全因死亡的AUC分别为0.677g/1和0.721（当截断点为10.647和0.1086时,其敏感性为89.4％和85.1％,特异性为67.7％和60.3％,P＜0.001）.多因素Logistic回归分析显示血红蛋白CV升高、年龄增加和CRP升高是MHD患者全因死亡独立危险因素.结论 MHD患者血红蛋白的变异性较大患者具有较高死亡危险度,血红蛋白的变异性可能有助于MHD患者全因死亡的预测.

Objective To determine the relationship between hemoglobin variability and mortality in maintenance hemodialysis （MHD） patients.Methods A total of 364 MHD cases were recruited from Shanghai Renal Registry Network.The relationship between hemoglobin variability and all-cause mortality was assessed.Results In the 364 MHD cases,the average age was 63.07±13.93 years,the dialysis vintage was 76.0 （42.25,134.0） months,and 85 patients （23％） died.The dead patients had a higher mean hemoglobin SD and CV comparing with the survival patients （19.19±6.31 vs.13.74±5.89,and 0.172±0.07 vs.0.126±0.056,respectively,P＜0.001）.Risk of all-cause mortality in patients in the upper quartile （P75） of hemoglobin SD was significantly higher than those in the lower quartile （P25） （OR=5.964,95％ CI 2.663 ～ 13.357,P＜ 0.001）,even after adjustment for demographic data,lifestyle factors and biochemical markers （OR=4.961,95％ CI 1.959～ 11.238,P＜0.001）.Kaplan-Meier method showed that patients with hemoglobin SD and CV in the upper quartile had a lower survival rate （P＜ 0.001）.ROC-AUC of hemoglobin SD and CV for all-cause mortality were 0.677 and 0.721,respectively （cutoff 10.647g/1 and 0.1086,respectively; accuracy 89.4％ and 85.1％,respectively; specificity 67.7％ and 60.3％,respectively; P＜0.001）.Multivariate logistic regression analysis showed that higher hemoglobin CV,older age and higher CRP were the independent risk factors for all-cause mortality.Conclusions The highest hemoglobin SD and CV were independently correlated with all-cause mortality.Hemoglobin variability may have prediction value for mortality in MHD patients.