不同钙离子浓度透析液对单次血液透析钙平衡的影响

Effects of different dialysate calcium concentrations on calcium mass balance during hemodialysis

目的观察三种不同钙离子浓度透析液对维持性血液透析患者单次透析过程中血钙的影响,为透析液钙离子浓度的个体化选择提供理论参考。方法选择2014年1月在哈尔滨医科大学附属第一医院血液净化中心接受维持性血液透析治疗的患者80例为研究对象,随机分为3组,根据使用不同钙离子浓度分别为1.25 mmol/L(DCa 1.25组)、1.5 mmol/L(DCa 1.50组)和1.75 mmol/L(DCa 1.75组)的透析液进行单次血液透析治疗,每次透析4 h,3组所用透析液除钙离子浓度不同外,其他透析液主要成分组间无差别。分别检测每组透析前、后及下一次透析前的血肌酐(SCr)、尿素氮(BUN)、血白蛋白(albumin,Alb)、血钙、血磷等生化指标,同时监测单次透析前后患者的血压变化。结果对患者透析前基线数据初步分析结果表明,透析前iPTH水平为(458.7±408.2)ng/L、血钙(2.2±0.2)mmol/L、血磷(2.1±0.6)mmol/L、钙磷乘积(57.4±18.9)。iPTH、血钙、血磷达标率分别为53.8%、46.3%,25.0%;透析患者普遍伴有低钙血症(占48.8%)、高磷血症(占71.3%)和高甲状旁腺素血症(占23.8%)。单次透析治疗结束后的血钙水平分别为DCa 1.25组(2.27±0.20)mmol/L、DCa 1.50组(2.53±0.21)mmol/L、DCa 1.75组(2.51±0.20)mmol/L,组间比较差异有统计学意义(F=12.52,P<0.01)。与透析前相比较,3组透析后血钙浓度较透析前均有所增加;协方差分析结果表明,在扣除透析前血钙浓度的影响因素后,DCa 1.25组血钙平均增加量最小。单次透析结束后血钙达标率分别为65.4%(DCa 1.25组)、48.1%(DCa 1.50组)、58.8%(DCa1.75组);透析结束后高钙血症的发生率DCa 1.75组(占41.2%)与DCa 1.50组(占51.9%)明显高于DCa 1.25组(占19.2%)。三种透析液对透析患者的血磷、血压影响差异均无统计学意义(P>0.05)。结论单次使用钙离子浓度为1.25 mmol/L的透析液治疗,对透析后血钙浓度的影响最小、血钙达标率最高、高钙血症的发生率最低;与钙离子浓度分别为1.50 mmol/L和1.75 mmol/L透析液比较,钙离子浓度1.25 mmol/L更接近人体生理离子钙浓度。

Objective To evaluate the effects of dialysate with three different calcium concentra- tions on serum total calcium in maintenance hemodialysis patients with a single dialysis. Methods In January 2014, this clinical study was carried out in the First Affiliated Hospital of Harbin Medical U- niversity, and 813 maintenance hemodialysis （MHD） outpatients were enrolled. Eighty MHD patients were randomly divided into three groups. DCa 1.25 （n = 29）, DCa 1.50 （n = 30） and DCa 1.75 （n = 21）. Patients in each group underwent three sessions of treatment of 4-h bicarbonate HD using dialy- sate with different concentrations of Ca. Ca concentrations for DCa 1.25, DCa 1.50 and DCa 1.75 groups were 1.25, 1.50 and 1.75 mmol/L, respectively. Levels of tCa, P and ALB in serum were as- sessed before and after each dialysis session. And changes in blood pressure were also investigated before and after single dialysis session. Results After single dialysis treatment, average levels of serum total calcium in DCa 1.25, DCa 1.50 and DCa 1.75 groups were （2. 27 ± 0. 20）, （2. 53 ± 0. 21） and （2. 51 ± 0. 20） mmol/L, respectively, with the differences being significant among the three groups （F = 12. 52, P〈0. 01）. The total calcium concentrations in the three groups were increased after HD sessions. The patients in DCa 1.25 group achieved the least increment of serum total calcium, when influence caused by serum total calcium concentration before HD sessions was ignored. After single di- alysis treatment, The standard rate of serum total calcium in DCa 1.25, DCa 1.50 and DCa 1.75 groups was 65.4%, 48. 1% and 58. 8% respectively. Hypercalcemia incidence in DCa 1.75 group （41.2%） and DCa 1.50 group （51.9%） was significantly higher than in DCa 1.25 group （19. 2%）. However, there was no statistically significant difference in serum phosphate and blood pressure. Conclusions Minimal effect on levels of total calcium was identified in DCa 1.25 group. In comparison with DCa 1.50 and DCa 1.75 groups, 1.25 mmol/L calcium was closer to the physiological concentra- tion of ionized calcium in the blood.