原发性单症状性夜遗尿症患儿醋酸去氨加压素不同减量方式的临床研究

Clinical effect of 1-desamino-8-D-Arginine Vasopressin different withdrawal ways in primary monosymptomatic nocturnal enuresis

目的观察醋酸去氨加压素（DDAVP）不同减量方式治疗原发性单症状性夜遗尿症（PMNE）患儿的疗效及复发情况，为临床上更好的使用DDAVP治疗PMNE提供参考依据。方法选取2014年11月至2016年6月我院就诊的PMNE患儿256例。采取随机数字表法将其随机分为A组（DDAVP立即停药组）65例、B组（DDAVP隔日减量组）58例及C组（DDAVP阶梯减量组）60例。DDAVP疗程3个月，治疗3个月后有效的患儿（完全应答和部分应答）进入减量阶段，A组立即停药观察，B组给予隔日口服2月后停药，C组给予每2～4周减量0.05 ～0.10 mg直至完全停药。停药后均随访3个月进行疗效判定。结果256例PMNE患儿最终有183例患儿完成本研究，其中A、B、C组分别为65、58、60例。治疗3个月A、B、C组的有效率分别为89.23%（58/65）、89.66%（52/58）和86.67%（52/60），差异无统计学意义（χ2＝0.309，P＝0.857）。A、B、C组分别有58、52、52例患儿进入减量阶段；停药1个月B组和C组的有效率分别为88.46%（46/52）和92.31%（48/52），明显高于A组有效率67.24%（39/58），差异均有统计学意义（χ2＝7.030，P＝0.008；χ2＝10.417，P＝0.001 ）；停药1个月B组和C组的复发率分别为19.23%（10/52）和17.31%（9/52），明显低于A组复发率36.21%（21/58），差异均具有统计学意义（χ2＝3.904，P＝0.048；χ2＝4.937，P＝0.026 ）。停药3个月C组的有效率为78.85%（41/52），明显高于A组50.00%（29/58）和B组57.69%（30/52），差异均有统计学意义（χ2＝9.859，P＝0.002；χ2＝5.371，P＝0.020 ）；停药3个月C组的复发率为32.69%（17/52），明显低于A组55.17%（32/58）和B组51.92%（27/52），差异具有统计学意义（χ2＝5.609，P＝0.018；χ2＝3.939，P＝0.047）；但停药3个月B组与A组间有效率和复发率相比差异均无统计学意义（χ2＝0.652，P＝0.419；χ2＝0.116，P＝0.733）。所有入选患儿无一例发生严重不良反应。结论DDAVP治疗3个月后进行逐渐减量能明显提高PMNE患儿疗效和减少复发；阶梯减量治疗方案的近期及远期疗效良好，而隔日减量治疗方案远期疗效欠佳。

Objective To explore the effect and compare the relapse rates of 1-desamino-8-D-Arginine Vasopressin（DDAVP） different withdrawal ways after initial 3 months in primary monosymptomatic nocturnal enuresis（PMNE） patients, in order to provide some evidences and references to use DDAVP to cure PMNE preferably. Methods Two hundred and fifty-six cases PMNE patients who were treated in Hubei Maternal and Child Health Hospital from November 2014 to June 2016 were selected and randomly divided into group A（DDAVP immediate withdrawal group, 65 cases）, group B（DDAVP day reduction group, 58 cases） and group C（DDAVP step reduction group, 60 cases）. All patients were given DDAVP tables for 3 months.After 3 months for DDAVP, patients who were effective（full respond and partial respond） to DDAVP continued to undergo a withdrawal stage, those in group A underwent immediate cessation, those in group B continued to receive the effective dose every other day for 2 months and those in group C were step by step tapered by 0.05-0.10 mg every 2-4 weeks until completely stopped, the period was not more than 3 months.All patients had a follow-up visit for 3 months after cessation of DDAVP.Results A total of 183 patients completed the study finally, there were 65 patients in group A, 58 patients in group B and 60 patients in group C. Initial 3 months the effective rates of group A, B and C were respectively 89.23%（58/65）, 89.66%（52/58） and 86.67%（52/60）, there were not statistically significant difference（χ2=0.309, P=0.857）. There were 58 patients in group A, 52 patients in group B and 52 patients in group C continued to undergo the withdrawal stage.One month after cessation of DDAVP, the effective rates of group B（88.46%, 46/52） and group C（92.31%, 48/52） were significantly higher than group A（67.24%, 39/58）（χ2=7.030, P=0.008; χ2=10.417, P=0.001）, while the relapse rates of group B（19.23%, 10/52） and group C（17.31%, 9/52） were significantly less than group A（36.21%, 21/58）（χ2=3.904, P=0.048; χ2=4.937, P=0.026）. Three months after cessation of DDAVP, the effective rates of group C（78.85%, 41/52） were significantly higher than group A（50.00%, 29/58） and group B（57.69%, 30/52）（χ2=9.859, P=0.002; χ2=5.371, P=0.020）, and the relapse rates of group C（32.69%, 17/52） were significantly less than group A（55.17%, 32/58） and group B（51.92%, 27/52）（χ2=5.609, P=0.018; χ2=3.939, P=0.047）, while the effective rates and relapse rates were not statistically significant difference between group A and group B（χ2=0.652, P=0.419; χ2=0.116, P=0.733）. Severe adverse events related to DDAVP were not observed in any patients.Conclusion Gradual withdrawal after initial 3 months of DDAVP may improve the effect and reduce the relapse rates, the short-term and long-term curative effects of step-by-step withdrawal treatment are both well, while long-term curative effects of every other day withdrawal treatment is not obviously well.