维持性血液透析患者血磷达标状况与颈动脉粥样硬化的关系

Maintaining serum phosphorus in the target range and its correlation with carotid atherosclerosis in maintenance hemodialysis patients with hyperphosphatemia

目的通过对维持性血液透析(maintenance hemodialysis,MHD)合并高磷血症的患者采用磷结合剂治疗,探讨血磷达标状况对MHD患者颈动脉粥样硬化(carotid atherosclerosis,AS)的影响。方法 1选择在上海市闸北区中心医院血液净化中心透析龄超过3个月的MHD患者80例,其中男44例,女36例,平均年龄(57.1±13.8)岁,平均透析龄(38.7±14.8)月;透析前血磷>1.78mmol/L,饮食保持稳定且依从性好;病情稳定,预期生存期>2年。2对所有入选患者进行降磷治疗,分别口服碳酸钙、醋酸钙、碳酸镧,共进行为期24个月随访,期间根据血磷和血钙的变化,及时调整药物品种和剂量。3分别于治疗前、治疗后6、12、18、24个月末检测患者的血磷、血钙、全段甲状旁腺激素(i PTH)、血红蛋白、血清白蛋白等;计算钙磷乘积和尿素清除指数(kt/V)。4分别于治疗前、治疗后12、24个月末行颈动脉超声检测。5在随访结束24个月末将资料完整的80例患者,根据血磷水平分为高血磷组(血磷≥1.78mmol/L)和正常血磷组(血磷<1.78mmol/L),分析血磷达标状况对MHD患者AS的影响。结果 1与治疗前比较,治疗后6、12、18、24个月患者血磷、i PTH及钙磷乘积均显著下降、血钙水平均显著升高(P<0.05或P<0.01);Hb、Alb及kt/V差异无统计学意义。2在随访结束后分析发现,与高血磷组比较,正常血磷组血磷、i PTH显著降低(P<0.05或P<0.01),血钙、Hb、Alb及kt/V的差异无统计学意义;颈动脉内膜中层厚度(IMT)及斑块形成、颈动脉硬化的患病率均显著降低(P<0.05或P<0.01)。3直线相关分析显示,血磷与i PTH及IMT、斑块形成、颈动脉硬化的患病率呈正相关、与血钙呈负相关(P<0.05或P<0.01)。4多因素逐步回归分析显示,血磷、i PTH和年龄是MHD患者AS的独立危险因素。结论高磷血症是MHD患者并发AS的危险因素之一,血磷达标状况与MHD患者AS的发生密切相关。

Objective To investigate the achievement of serum phosphorus in the target range, and its correlation with carotid atherosclerosis （AS） in maintenance hemodialysis （MHD） patients with hyperphospha-temia and treated with phosphate binders. Methods We recruited 80 patients subjected to MHD for at least 3 months and with serum phosphorus 〉1.78 mmol/L. They were given one of the three phosphate binders for 2 years. Phosphate binder and its doses were adjusted to obtain serum phosphorus in target range. Serum phos-phorus, calcium and intact parathyroid hormone （iPTH） were assayed every 6 months during the treatment pe-riod. Carotid ultrasonography was performed to detect AS. After the therapy for 2 years, the patients were di-vided into high serum phosphorus group （≥1.78 mmol/L, n=50） and normal serum phosphorus group （〈1.78 mmol/L, n=30）. Results After the treatment for 6 months, serum phosphorus and iPTH decreased signifi-cantly and serum calcium increased significantly in all patients as compared with these parameters before treatment （P〈0.05 or 〈0.01）. Serum phosphorus and iPTH decreased gradually with the duration of phos-phate binder therapy. Serum phosphorus and iPTH, carotid intimal medial thickness （IMT）, and the preva-lence of AS were lower in normal serum phosphorus group than in high serum phosphorus group （P〈0.05 or 〈0.01）. Serum phosphorus was positively correlated with the levels iPTH and IMT and the prevalence of AS in all MHD patients with hyperphosphatemia （P〈0.05 or 〈0.01）. A negative correlation was found be- 〈br〉 tween serum levels of phosphorus and calcium （P〈0.05）. Conclusion Hyperphosphatemia is a significant and independent risk factor of the advanced arteriosclerosis in MHD patients. Maintaining serum phosphorus concentration in the target range is effective to decrease the prevalence of AS in MHD patients.