高通量血液透析联合左卡尼汀治疗对维持性血液透析患者营养状况和生存质量的影响

Effect of high flux hemodialysis combined with levocarnitine therapy on nutritional status and quality of life in maintenance hemodialysis patients

目的:探讨高通量血液透析(HFHD)联合左卡尼汀治疗对维持性血液透析(MHD)患者营养状况和生存质量的影响。方法:选择MHD治疗患者100例为研究对象,随机分为3组:A组:高通量血液透析(HFHD)+左卡尼汀组(34例);B组:HFHD组(32例);C组:低通量血液透析(LFHD)组(34例)。A组患者每次透析结束后静脉给予左卡尼汀注射液1.0 g。3组患者均于治疗前及治疗6个月时检测血常规、超敏C反应蛋白(hs-CRP)、全段甲状旁腺激素(iPTH)、β_2-微球蛋白(β_2-MG)、白介素-6(IL-6)及血脂、白蛋白(ALB)、尿素氮(BUN)、肌酐(Scr)、总钙(T-Ca)等生化指标,计算尿素清除指数(KT/V)值,并应用SF-36健康调查简表对患者进行问卷调查。记录3组患者透析过程中发生高血压、低血压、肌肉痉挛、心律失常、瘙痒和不宁腿等并发症发生情况。结果:1生活质量评价量表(SF-36)评分:研究前3组SF-36量表评分无统计学差异(P>0.05),6个月后A组SF-36评分高于B组,A和B组均高于C组,与治疗前相比,A组患者的SF-36量表8个维度得分均明显升高(均P<0.05);B组在生理功能(PF)、生理职能(RP)、躯体疼痛(BP)、总体健康(GH)、精力(VT)、精神健康(MH)6个维度得分较前明显升高(均P<0.05);C组各维度得分差异无统计学意义(均P>0.05)。2血液检测指标:与治疗前相比,A、B 2组Hb、白蛋白(Alb)水平均升高,且A组高于B组(均P<0.05);A、B 2组hs-CRP、IL-6、β_2-MG、血磷(P3-)、i PTH、总胆固醇(CHOL)、低密度脂蛋白(LDL)和脂蛋白a(Lp(a))水平较治疗前明显下降(均P<0.05),且A组hs-CRP、IL-6、甘油三脂(TG)、LDL和Lp(a)下降优于B组,C组各指标变化无统计学差异(均P>0.05)。治疗前、后3组患者BUN、CREA、KT/V、T-CA组间、组内比较均无统计学差异(均P>0.05)。3并发症发生率:A组最低,C组最高(均P<0.05)。结论:HFHD对小分子毒素的清除与LFHD效果相当,但对β_2-MG、IL-6、i PTH、hs-CRP等中大分子物质清除效果优于LFHD,并能更有效降低血磷,若同时联合左卡尼汀治疗,则能更有效改善患者的微炎症状态、脂质代谢紊乱和营养状况,减少透析相关并发症的发生率,从而全面提高维持性血液透析患者的生存质量。

Objective： To investigate the effect of high flux hemodialysis（ HFHD） combined with levocarnitine therapy on the nutritional status and quality of life in maintenance hemodialysis patients. Methods： A total of 100 cases of maintenance hemodialysis treated in Outpatient Department of Wuhan Fifth Hospital from June 2014 to December were randomly divided into 3 groups. In group A,the 34 patients in total were given L-carnitine injection treatment at the end of each HFHD.The 32 patients in group B were just treated with HFHD,and 34 patients were treated with low flux hemodialysis（ LFHD） in group C. Before and 6 months after treatment,blood routine,the biochemical indicators,high-sensitive C-reactive protein（ hs-CRP）,intact parathyroid hormone（ i PTH）,beta 2 microglobulin（ β2-MG） and interleukin-6（ IL-6） were respectively analyzed,and the KT / V ratio was calculated. Meanwhile these patients were surveyed with SF-36 health survey questionnaire. During the treatment,the complications including high blood pressure,low blood pressure,muscle spasms,arrhythmia,itching,symptoms of restless legs in the process of dialysis in each group were recorded. Results： 1SF-36 scale score：Before the treatment,there was no statistically significant different among the groups（ P〉0. 05）. SF-36 scale score in group A was higher than in group B,and that in groups A and B was higher than in group C. And 8-dimension scores of the SF-36 scale after treatment in group A were higher than before treatment（ P〈0. 05）. Six-dimension scores called physical functioning（ PF）,role-physical（ RP）,bodily pain（ BP）,general health（ GH）,vitality（ VT）,and mental health（ MH） in group B after treatment were increased as compared with those before treatment（ P〈0. 05）. Each dimension score in groupC showed no statistically significant difference before and after treatment（ P〉0. 05）. 2The blood test indexes： there was no significant difference in the levels of blood routine,biochemical and immune indexes among the three groups before the treatment（ P〉0. 05）. After the treatment,the levels of Hb and Alb were increased in both groups A and B,and changes in group A were more obvious with statistically significant（ P〈0. 05）. The concentrations of hs-CRP,IL-6,P3-,β2-MG,i PTH,CHOL,LDLC and Lp（ a） after the treatment in groups A and B were decreased as compared with those before the treatment（ P〈0. 05）. In addition to P3-,i PTH and β2-MG,the concentrations of hs-CRP,IL-6,CHOL,LDLC,TG and Lp（ a） in group A were lower than those in group B（ P〈0. 05）. Before and after the treatment,all the indices above in group C showed no significant changes. The changes of BUN,Scr,KT / V ratio and T-ca in all groups showed no statistically significant difference（ P〉0. 05）. 3Comparison of the incidence of complications： The incidence of complications in group A was the lowest,followed by group B,and highest in group C. Comparison between groups showed statistically significant difference（ P〈0. 05）. Conclusion： For small molecule toxins removal,the effect of HFHD and LFHD was the same. For the macromolecules like β2-MG,IL-6 and i PTH,HFHD was better,and HFHD can also reduce the blood phosphorus more effectively. At the same time,the therapy of HFHD combined with L-carnitine can improve the patients＇ microinflammation state,lipid metabolic disorder and nutritional status effectively. Thereby the therapy of HFHD combined with L-carnitine can reduce the incidence of dialysis-related complications and improve each dimension score of the PF,RP,BP,GH,functions of emotion（ RE）,social function（ SF）,MH,VT and improve the nutritional status and quality of life in maintenance hemodialysis patients.