湘潭地区终末期肾脏病维持性血液透析患者现况调查

A survey of end- stage renal disease patients with maintenance hemodialysis in Xiangtan district

目的 了解湘潭市终末期肾脏病（end stage renal disease,ESRD）维持性血液透析（maintenance hemodialysis,MHD）患者的病因构成、年龄分布、并发症控制、血液传播性疾病阳性率和医疗负担现状.方法 收集2014年11～12月湘潭市所有血液透析中心维持性血液透析病例1166例,采用问卷调查、查阅病历及实验室检查等方法,采集病例信息（包括患者基本信息、原发病诊断、并发症及合并症、血液透析治疗信息、药物治疗信息、透析前血压、血红蛋白（hemoglobin,Hb）、血磷、血钙、血清全段甲状旁腺激素、血液传播性疾病、医疗费用和医疗保险模式等信息）并进行分布特征描述.结果 1166例维持性血液透析患者中,男女之比为1.3∶1,平均年龄（54.4±13.2）岁,透析龄范围3个月～20年,透析龄中位数2.0年;前5位原发病分别为慢性肾小球肾炎487例（41.8％）,糖尿病肾病279例（23.9％）,高血压肾损害260例（22.3％）,梗阻性肾病51例（4.4％）,多囊肾33例（2.8％）,近2年的新发病例中糖尿病肾病比例29.7％;患者每周平均透析治疗时间6～10h者占54.2％,≥10h者占38.2％;并发症治疗达标情况：高血压达标率35.8％;血红蛋白达标率41.4％;血磷达标率30.1％,血钙达标率58.3％,全段甲状旁腺激素达标率46.8％.透析患者死亡原因主要为心血管事件（42.4％）、感染（21.6％）、脑血管事件（12.9％）.患者月均医疗费用为（4746.1±1094.1）元;患者医疗保险模式以农合医疗（48.2％）以及职工医保（40.6％）为主,全自费仅仅占1.3％;血液传播性疾病阳性率：乙型肝炎6.69％,丙型肝炎3.52％,梅毒1.03％;所有被调查患者中血液透析后丙型肝炎转阳2例,乙型肝炎及梅毒均为0例.结论 湘潭地区维持性血液透析患者中原发疾病以慢性肾小球肾炎为主,其次为糖尿病肾病和高血压肾病;首次透析年龄集中在36～59岁年龄段,每周透析治疗时间6～10h/w为主,高血压、肾性贫血、高磷血症、继发性甲状旁腺亢进等并发症达标率较低,治疗依从性及规范性仍需有待加强;血液透析后血液传播性疾病转阳率低,感染控制措施到位.

Objective To investigate etiology, age distribution, complication management, blood-borne diseases, and medical burden of end-stage renal disease （ESRD） patients on maintenance hemodialysis （MHD） in Xiangtan district. Methods A total of 1,166 patients were recruited in the period of Nov. to Dec. 2014 from 9 dialysis centers in Xiangtan district. Questionnaire information, medical records, laboratory tests, case information （including basic patient information, primary renal disease, complications, comorbidities, he-modialysis modalities, medication, pre-dialysis blood pressure, hemoglobin, phosphorus, calcium, serum in- tact parathyroid hormone, blood-borne diseases, medical expenses, medical insurance,etc） were collected, and then a descriptive study was performed. Results In the 1,166 MHD patients, the male to female ratio was 1.3：1, the average age was 54.4±13.2 years, and the median dialysis age was 2.0 years （3 months-20 years）. The top 5 primary diseases were chronic glomerulonephritis （n=487, 41.8% ）, diabetic nephropathy （n=279, 23.9%）, hypertensive nephropathy （n=260, 22.3%）, obstructive nephropathy （n=51, 4.4%）, and polycystic kid- ney disease （n=33,2.8%）. The proportion of newly diagnosed diabetic nephropathy in the recent 2 years was 29.7%. Patients spent 6-10 hours/week for dialysis in 54.2% patients and ≥10 hours/week in 38.2% patients. The required levels achieved in 35.8% patients for blood pressure, 41.4% patients for hemoglobin, 30.1% patients for serum phosphorus, 58.3% patients for serum calcium, and 46.8% patients for intact parathyroid hor-mone （iPTH）. The main cause for death in MHD patients was cardiovascular events （42.4%）, followed by infections （21.6%）, and cerebrovascular events （12.9%）. The average medical expense was 4,746.1±1,094.1 yuan/month. Medical expenses could be covered by rural cooperative medical insurance （48.2%） or medical in- surance for employees （40.6%）, and only 1.3% patients needed to pay the expenses by themselves. Hepatitis B infection was found in 6.69% patients, hepatitis C in 3.52% patients, and syphilis in 1.03% patients. After hemodialysis, two patients turned to be hepatitis C positive, but none became hepatitis B or syphilis positive. Conclusion The main primary disease for MHD in Xiangtan district was chronic glomerulonephritis, followed by diabetic nephropathy and hypertensive nephropathy. Dialysis began at 36-59 years of age, and the dialysis time was 6-10 hours/week. The ratio of patients achieved the required levels for blood pressure, hemo-globin, phosphorous, calcium and iPTH were still low. Patient compliance and standardization of dialysis need to be improved further. The rate of blood-borne diseases caused by hemodialysis was low, indicating the effectiveness of infection control in dialysis.