血液透析患者血清钙磷甲状旁腺激素达标状况及与死亡的关系

The serial changes and status on achieving serum phosphorus calcium, iPTH targets and their associations with mortality in hemodialysis patients: a retrospective study

目的 探索血液透析（hemodialysis,HD）患者血清钙、磷、全段甲状旁腺激素（intact parathyroid hormone,iPTH）的达标情况、动态变化及其与死亡的关系.方法 单中心回顾性纵向调查,2012年1～12月北京航天总医院肾内科HD患者.据K/DOQI指南,评估血清钙、磷、iPTH达标情况及动态变化. 结果 92例HD患者纳入研究.研究期间,79例存活,13例死亡,其中7例死于心血管事件,6例死于脑血管事件.92例患者,从基线开始的5次评估中,校正钙达标率波动大（17.7％～29.1％,P＜0.05）;血磷达标率变化无统计学意义（34.5％～29.1％,P＞0.05）;iPTH达标率有改善趋势（29.3％～36.7％）,但差异无统计学意义（P＞0.05）.活性维生素D或磷结合剂使用率无明显变化（P＞0.05）.钙磷二者均达标（7.6％～13.0％）或者钙磷iPTH三者共同达标率（1.3％～4.3％）低.高磷组iPTH水平高于血磷＜1.78mmol/L组（P＜0.05）;全部5次评估,透析龄≥18months组iPTH水平明显高于透析龄＜18months组（P＜0.05）,iPTH水平在血钙＜2.10mmol/L与血钙≥2.10mmol/L组间差异无统计学意义（P＞0.05）.多变量回归分析显示长透析龄（0R=1.052,95％CI 1.017～1.069）,合并心脑血管事件（0R=252.17,95％CI 11.54～550.8）与死亡风险正相关,高血清白蛋白与死亡风险负相关（OR=0.700,95％ CI 0.506～0.969）.钙磷iPTH达标状态对患者死亡影响无统计学意义（P＞0.05）. 结论 北京航天总医院肾内科HD患者校正钙、血磷及iPTH持续达标率低,随时间发展无明显改善.高磷和长透析龄影响iPTH达标.未发现钙、磷及iPTH达标状态对HD患者死亡有显著影响.

Objective To investigate the serial changes and the status on achieving serum phosphorus（P）,calcium（Ca）,intact parathyroid hormone（iPTH） targets in hemodialysis（HD） patients,and explore their correlations with mortality.Methods The authors performed a single-center retrospective study of HD patients from Beijing Aerospace General Hospital,between January 2012 and December 2012,evaluating the status on achieving the targets for Ca and P and iPTH set by the K/DOQI guideline,and serial changes in Ca,P and iPTH values at each scheduled visit.Ninety-two patients were eligible for this study.Results During the study period,in the ninety-two patients,seventy-nine patients survived,and thirteen patients died,of whom seven died of cardiovascular disease,six died of cerebrovascular events.The percentages of patients within the Ca target were low and varied significantly （from 29.3％ to 17.7％,P＜0.05）.There was no notable improved trend in the percentages of patients within P target from 34.8％ to 29.1％ over one year （P＞0.05）.The percentages of patients within the iPTH target increased from initial 29.3％ to 43％ at visit 4,the difference was not statistically significant （P＞0.05）.The rate of patients who achieved both serum Ca and P levels consistent within the targets was 7.6％ at reference visit and 13.0％ at visit 5.The rates of patients who simultaneously achieved the Ca,P,iPTH targets was 1.3％ to 4.3％.There were no remarkable changes in the rates of patients receiving vitamin D or phosphate binders （P＞0.05） during the study.The levels of iPTH at visit 4,5 were higher in hyperphosphataemia group than those in the serum P ＜1.78mmol/L group （P＜0.05）.Compared with dialysis duration ＜ 18months group,serum iPTH levels at all the evaluation times were significantly higher in dialysis duration ≥ 18months group （P＜0.05）.On the contrary,iPTH levels at each scheduled visit were not significantly different between the Ca＜2.10mmol/L group and the Ca≥ 2.10mmol/L group （P＞ 0.05）.Multivariate logistic regression analysis demonstrated that longer dialysis duration （OR=1.052,95％ CI 1.017-1.069） and complicated by cardio cerebrovascular events （OR=252.17,95％ CI 11.54-550.8） were positively associated with mortality,higher serum albumin was negatively associated with mortality （OR=0.700,95％ CI 0.506 to 0.969）.Cox regression analysis showed that low and high calcium,high and low P,high iPHT and low iPTH were not associated with mortality after adjusting the covariates （all P＞0.05）.Conclusion The achievement rates of serum Ca and P and iPTH targets set by K/DOQI were low in our hospital.Hyperphosphataemia and longer dialysis duration inhibited the achievement rate of serum iPTH guideline target.The status on sustained achieving serum Ca,P,iPTH targets had no significant influence on the mortality of HD patients in this study.Further exploration is required.