维持性透析患者出血性脑卒中早期死亡影响因素分析

Risk factors for early death due to hemorrhagic stroke in maintenance dialysis patients

目的出血性脑卒中是维持性透析患者致残、致死的严重并发症。本研究回顾性分析第三军医大学大坪医院野战外科研究所肾内科血液透析和腹膜透析出血性脑卒中发生率,30天死亡率及其影响因素。方法回顾性分析711例透析患者出血性脑卒中发生率及死亡率,比较出血后30天死亡及存活2组患者临床指标,以分析影响早期预后的相关因素。结果共计29例患者发生出血性脑卒中,其中血液透析26例,腹膜透析3例。与腹膜透析相比,血液透析患者出血性脑卒中发生率更高(66.5vs.10.5/10,000病人年,P=0.002);血液透析与腹膜透析出血性脑卒中死亡率分别为73.1%和66.7%。死亡组脑出血时收缩压、脑出血时舒张压、出血量、脑室血肿发生率、i PTH均显著高于存活组,glasgow昏迷评分显著低于低于存活组(P<0.05)。Spearman相关性分析发现脑出血时收缩压(r=0.562,P=0.004)、脑出血时舒张压(r=0.569,P=0.004)、出血量(r=0.612,P=0.001)、脑室血肿(r=0.402,P=0.042)、i PTH(r=0.510,P=0.011)、glasgow昏迷评分(r=-0.567,P=0.001)与30天死亡显著相关。Kaplan-Meier生存曲线显示出血性脑卒中后透析方式对生存时间无影响(Log-Rank,P=0.545)。结论本组维持性透析患者中,出血性脑卒中时血压水平、出血严重程度、i PTH水平与出血性脑卒中30天死亡相关,出血性脑卒中后采用连续性肾脏替代治疗或腹膜透析对早期预后无显著影响。

Objective Hemorrhagic stroke （HS） is a severe complication causing death and disability in maintenance dialysis patients. This study retrospectively investigated the incidence of HS, 30-day mortality and the risk factors for death in hemodialysis （HD） and peritoneal dialysis （PD） patients in a single center. Methods A total of 711 dialysis patients in our center were enrolled in this study. Twenty-nine patients with HS were divided by the outcome within 30 days into death group and survival group. Clinical and laboratory characteristics were compared between the two groups. Results HS occurred in 29 patients （26 cases on HD, 3 cases on PD）, significantly higher in HD patients than in PD patients （66.5/10,000 vs. 10.5/10,000 pa- tient per year, P=0.002）. Its mortality was 73.1% in HD patients and 67.7% in PD patients. Systolic blood pres- sure （SBP） at admission, diastolic blood pressure （DBP） at admission, size of hemorrhage area, incidence of intraventricular hematoma, and serum iPTH were significantly higher, and Glasgow coma score （GCS） were significantly lower （P〈0.05） in death group than in survival group. The 30-day mortality was correlated with SBP at admission （r=0.562, P=-0.004）, DBP at admission （r=0.569, P=0.004）, intraventricular hematoma （r= 0.402, P=0.042）, size of hemorrhage area （r=0.612, P=0.001）, iPTH （r-=0.510, P=0.011）, and GCS （r=-0.567, P=-0.001）. Kaplan-Meier curve showed that dialysis modality after HS had no impact on survival time of the patients （Log-rank test, P=0.545）. Conclusion The 30-day mortality of HS was related to blood pressure at admission, severity of hemorrhagic stroke, and serum iPTH level in maintenance dialysis patients. Continuous renal replacement therapy and peritoneal dialysis after HS had no impact on their early outcome.