新发腹膜透析患者残余肾功能下降的影响因素分析

Analysis of predictive factors for the decline of residual renal function in new peritoneal dialysis patients

目的寻找能够预测腹膜透析（PD）患者残余肾功能（RRF）下降的因素。方法选取本科腹膜透析中心的新入PD患者84例，建立回归模型，进行临床全面评估，观察以下指标：腹膜炎发生次数、血浆白蛋白、收缩压、舒张压、24h尿量、24h尿蛋白、C反应蛋白（CRP）、是否患有糖尿病、是否使用血管紧张素转化酶抑制剂（ACEI）或血管紧张素受体阻滞剂（ARB）类药物、心功能分级、水钠潴留情况及生化指标等，分析其与RRF下降的关系。终点事件定义为连续2次尿量≤100ml／24h。结果平均随访时间为（11．7±1．1）个月，发生终点事件的人数为20例，占23．8％，终点事件发生的平均时间为（10．5±2．0）个月。与未发生终点事件的患者相比，发生终点事件的患者有较高的超滤量[（551．6±328．2）ml比（294．1±288．0）ml，P=0．001]、较高的收缩压[（145．2±16．5）mmHg比（136．0±13．8）mmHg，P=0．016]、较差的心功能分级[（1．7±0．8）比（1.3±0．4），P=0．0001、较重的水钠潴留情况[（1．0±0．7）度比（0．6±0．5）度，P=0．0121、较高的腹膜炎发生率（35．0％比4．7％，P=0．000）、较低的Kt／V[（1．7±0．4）比（2．0±0．3），P=0．003]、较低的Hb水平[（89．0±14．9）g／L比（99．5±17．8）g/L，P=0．020]、较高的CRP水平[（19．4±34．4）mg／L比（8．7±12．6）mg/L，P=0．017]、较高的Ser水平[（1004．6±291．1）μmol／L比（753．1±254．3）μmol／L，P=0．0001、较低的血钙水平[（1．9±0．1）mmol／L比（2．0±0．2）mmol／L，P=0．000]、较高的血磷水平[（2．1±0．6）mmol／L比（1．6±0．4）mmol／L，P=0．001]以及较高的钙磷乘积[（3．8±1．1）mmol^2／L^2比（3．1±0．8）mmol^2／L^2，P=0．010]。Cox逐步回归分析结果提示，超滤量、心功能分级水平、腹膜炎发生率、Kt／V及血磷水平是患者残余。肾功能下降的重要影响因素。结论PD患者较高的Kt／V对残余肾功能起保护作用，而超滤量越大、心功能越差、腹膜炎发生率越高及血磷水平越高则RRF下降越显著。

Objective To prospectively evaluate the risk factors for the decline of residual renal function （RRF） in new peritoneal dialysis （PD） patients. Methods A total of 84 new PD patients in our PD center were included in this study, Clinical comprehensive assessment were made, and regression models was established to analyze the relationship between the decline of RRF and clinical indicators, which included the rate of peritonitis, systolic pressure, diastolic pressure, urine volume, 24 h urinary protein, serum albumin, C-reactive protein（CRP）, history of diabetes mellitus, and the use of angiotensin converting enzyme inhibitor （ACEI） or angiotensin receptor blockers （ARB） drugs, cardiac functional grading, sodium and water retention and biochemieal indicators. The primary outcome was defined as two consecutive urine volume ≤ 100 ml/24 h. Results The mean follow-up time was （11.7± 1.1） months, primary outcome occurred in 20 patients, accounting for 23.8%, and their average period progressed to the primary outcome was （10.5±2.0） months. The 20 patients had higher ultrafiltration volume [（551.6±328.2） ml vs （294.1±288.0） ml, P=0.001], higher systolic blood pressure [（145.2± 16.5） mmHg vs （136.0±13.8） mmHg, P=0.016], worse cardiac functional grading [（1.7±0.8） vs （1.3±0.4）, P=0.000], more serious water-sodium retention [（1.0±0.7） vs （0.6±0.5）, P=0.012], higher peritonitis rates （35.0% vs 4.7% ,P=0.000）, lower Kt/V [（1.7 ± 0.4） vs （2.0 ± 0.3）, P=0.003], lower hemoglobin levels [（89.0± 14.9） g/L vs （99.5 ± 17.8） g/L, P=0.020], higher C- reactive protein levels [（19.4±34.4） mg/L vs（8.7±12.6） mg/L, P=0.017], higher Scr levels [（1 004.6±291.1） μmol/L vs （753.1± 254.3） μmol/L, P=0.000], lower serum calcium levels[（1.86 ±0.1） mmol/L vs （2.02 ±0.2） mmol/L, P= 0.000], higher serum phosphorus [（2.1±0.6） mmol/L vs （1.6±0.4） mmol/L, P=0.001] and higher calcium phosphorus product [（3.8±1.1） mmol^2/L^2 vs （3.1±0.8） mmol^2/L^2, P=0.010] as compared with those of the patients without the primary outcome. Based on the results of muhivariable Cox regression analysis, uhrafihration volume, cardiac functional grading, peritonitis, Kt/V and serum phosphorus level contributed to the decline of RRF significantly, Conclusion The higher Kt/V in PD patients plays a protective role, the higher ultrafihration volume, the worse heart function, the more peritonitis rate and higher serum phosphorus predict more rapid declination of RRF.