维持性透析患者的蛋白能量消耗情况及影响因素分析

Protein-energy wasting and its related factors in maintenance dialysis patients

目的 探讨维持性透析患者蛋白能量消耗（protein-energy wasting PEW）情况,分析其影响因素。方法 选择2012年3月-2015年3月泰兴市人民医院收治的维持性透析患者154例,其中腹膜透析56例,血液透析98例。运用改良SGA法评分系统（modified quantitative subjective and global assessment,MQMGA）、营养不良-炎症评分（malnutrition-inflammation score,MIS）和白蛋白等进行营养评估,采用酶联免疫法检测血清超敏C反应蛋白（Serum hypersensitive c-reactive protein Hs-CRP）、肿瘤坏死因子（tumor necrosis factor-a,TNF-a）、白介素-6（interleukin-6,IL-6）浓度进行微炎症状态评估,同时检测人体学指标[身高、体质量、体质量指数（body mass index BMI）、中臂围（midarm circumference MAC）、肱三头肌皮褶厚度（triceps skin-fold TSF）,和中臂肌围（mid-arm circumference MAMC）]、生化指标[血清白蛋白（serum albumin Alb）、血清总蛋白（serum total protein TP）、血清前白蛋白（prealbumin PA）、血红蛋白（hemoglobin Hb）、转铁蛋白（transferrin TF）血肌酐（serum creatinine Scr）、尿素氮（urea nitrogen BUN）、胆固醇（cholesterol Tch）]等。分组标准：按照国际肾脏营养及代谢协会专家组制定的PEW的标准进行筛选,分为PEW组61例及非PEW组93例。结果1维持性透析患者PEW发生率39.6%（61/154）,其中血液透析患者PEW发生率40.8%（40/98）,腹膜透析患者PEW发生率37.5%（21/56）;血液透析与腹膜透析PEW发病率比较无统计学意义,（χ2=0.163,P=0.685）。2两组比较,在原发病方面,PEW组糖尿病肾病比例显著高于非PEW组（χ2=5.750,P=0.016）;PEW组年龄（t=5.666,P〈0.001）、透析时间（t=7.718,P〈0.001）、Hs-CRP（t=5.849,P〈0.001）、TNF-a（t=7.384,P〈0.001）、IL-6（t=7.650,P〈0.001）明显高于非PEW组;而BMI（t=2.514,P=0.006）、TP（t=7.237,P〈0.001）、ALB（t=2.905,P=0.001）、PA（t=9.168,P〈0.001）、TF（t=2.890,P=0.002）、Hb（t=5.791,P〈0.001）、Tch（t=3.048,P=0.001）、MAC（t=2.640,P=0.004）、MAMC（t=1.781,P=0.038）、Kt/V≥1.2的比例（χ2=9.518,P=0.002）明显低于非PEW组;3多因素分析显示,高龄（OR 1.442,95%CI 1.234-4.031,P=0.027）、透析时间长（OR 1.442,95%CI 1.234-4.031,P=0.027）、微炎症状态（OR 3.231,95%CI1.453-4.346,P=0.028）、低蛋白血症（OR 2.123,95%CI 1.443-3.722,P=0.046）、Kt/V〈1.2（OR3.674,95%CI 1.125-5.871,P=0.035）是导致PEW的独立危险因素。结论 维持性透析患者PEW发生率较高,维持性血液透析患者PEW发生率高于腹膜透析患者,但差异无统计学意义。高龄、透析龄、微炎症状态、透析不充分是PEW的独立危险因素。

Objective To investigate protein-energy wasting （PEW） status and its related factors in maintenance dialysis patients. Methods A total of 154 maintenance dialysis patients （88 males and 66 females; 25-72 years old; 56 peritoneal dialysis patients and 98 hemodialysis patients） treated in Taixing People＇s Hospital during the period from Mar. 2012 to Mar. 2015 were enrolled in this study. PEW status was assessed by Modified Quantitative Subjective and Global Assessment （MQSGA）, Malnutrition-Inflammation Score （MIS） and serum albumin level. Inflammation status including serum hypersensitive C-reactive protein （hsCRP）, tumor necrosis factor （TNF-ct） and interleukin 6 （IL-6） were measured by enzyme-linked immunoassay （ELISA）. Anthropometrical parameters including body height, body weight, body mass index （BMI）, midarm circumference （MAC）, triceps skin-fold （TSF）, and mid-arm muscle circumference （MAMC） were mea- sured. Serological markers including total protein （TP）, albumin, prealbumin （PA）, hemoglobin （Hb）, transferring （TF）, creatinine （Scr）, urea nitrogen （BUN）, total cholesterol （Tch） were also assayed. The diagnosis of PEW was made base on the standards from International Society of Renal Nutrition and Metabolism （ISRNM）. The patients were then divided into PEW group （n=61） and non-PEW group （n=93）. Results （1）PEW was found in 61 （39.6%） maintenance dialysis patients. PEW was found in 40 （40.8%） hemodialysis patients and 21 （37.5%） peritoneal dialysis patients without statistical significance between the two groups （x2=0.163, P=0.685）. （2）The ratio of diabetic nephropathy was more in PEW group than in non-PEW group （x2=5.750, P= 0.016）. Age （t=5.666, P〈0.001）, dialysis duration （t=-7.718, P〈0.001）, hsCRP （t=5.849, P〈0.001）, TNF-α （t=-7.384, P〈0.001）, and IL-6 （t=-7.650, P〈0.001） were higher in PEW group than in non-PEW group, while BMI （t=2.514, P=0.006）, TP （t=7.237, P〈0.001）, Alb （t=2.905, P=0.001）, PA （t=-9.168, P〈0.001）, TF （t= 2.890, P=0.002）, Hb （t=5.791, P〈0.001）, Tch （x2=3.048, P=0.001）, MAC （t=-2.640, P =0.004）, MAMC （t= 1.781, P=0.038）, and the proportion of Kt/V≥1.2 （x2=9.518, P= 0.002） were lower in PEW group than in non- PEW group. （3）Multifactorial analyses showed that advanced age （OR=1.442, 95% CI=1.234-4.031, P= 0.027）, longer dialysis duration （OR=1.442, 95% CI=-1.234-4.031, P=0.027）, inflammatory state, hypoalbu- minemia （OR=3.231, 95% CI=1.453-4.346, P=0,028）, and Kt/V 〈1.2 were the independent risk factors for PEW. Conclusion PEW was frequently seen in maintenance dialysis patients. Advanced age, longer dialysis duration, inflammatory state, and inadequate dialysis were the independent risk factors for PEW.