单中心20年间维持性血液透析患者首次透析原因分析

Analysis of the causes of initiating dialysis in maintenance hemodialysis patients in a single center for 20 years

目的分析北京医院肾内科血液净化中心20年间血液透析患者原发病构成,糖尿病肾病(diabetic nephropathy,DN)患者及非DN患者临床表现及首次透析原因差异,及血管通路使用情况。方法收集1994-2015年间开始维持性血液透析(maintenance hemodialysis,MHD)的患者。记录患者原发病及导致首次透析的直接原因,开始透析时血管通路情况及首次透析前实验室检查结果。分析DN和非DN患者及前后10年间上述指标差异。结果共收集289例患者。肾小球肾炎、DN和高血压肾病是前三位主要病因,DN患者比例近10年明显上升(16.000%上升至21.296%)。DN患者开始MHD时血肌酐水平低[(659.036±350.533)μmol/L对比(877.452±386.593)μmol/L,t=3.789,P<0.001],贫血严重[(86.839±18.890)g/L对比(93.092±22.795)g/L,t=2.064,P=0.041]、血磷[(1.648±0.481)mmol/L对比(2.006±0.753)mmol/L,t=3.865,P<0.001]和全段甲状旁腺素(intact parathyroid hormone,i PTH)[(236.150±203.332)pg/ml比(460.647±480.166)pg/ml,t=2.766,P=0.007)低,但酸中毒不明显(t=-2.483,P=0.014)。DN患者进入MHD的原因以心力衰竭/水肿为主,非DN患者以尿毒症症状为主。近10年所有患者血尿素氮明显升高(30.427±14.519mmol/L比24.865±7.517mmol/L,t=-1.312,P=0.036),但血钾[(4.676±0.945)mmol/L比(5.200±0.745)mmol/L,t=1.880,P=0.037]、血钙[(2.154±0.369)mmol/L比(2.395±0.270)mmol/L,t=2.033,P=0.037]、i PTH[(399.920±435.836)pg/ml比(968.000±705.377)pg/ml,t=2.399,P=0.020]控制明显优于10年前。深静脉置管在进入MHD时最常用。动静脉内瘘的比例无明显变化。结论北京医院肾内科血液净化中心MHD患者的原发病构成中第1位为肾小球肾炎,但DN比例明显上升。DN患者进入MHD的时机更早,常因顽固心力衰竭/水肿开始首次血液透析。与10年前相比,慢性肾脏病(chronic kidney disease,CKD)并发症控制更佳。但需重视CKD患者AVF的建立时机及使用。

Objective To analyze the primary disease, the difference in clinical manifestation and the reason for initiating dialysis between diabetic nephropathy（DN） group and non-DN group, and the vascular access in the hemodialysis patients in our center in the recent 20 years. Methods We recruited the patients initiating the maintenance hemodialysis（MHD） during 1994 to 2015. Their primary disease, the direct cause leading to dialysis initiation, vascular access and laboratory tests were recorded. The differences in these parameters in DN and non-DN patients between the first 10-year period and the second 10-year period in 1994-2015 were compared. Results A total of 289 patients were recruited. The leading primary disease was glomerulonephritis, followed by DN and hypertension. The proportion of DN patients increased significantly（16.000% to 21.296%） in the second 10-year period. At the initiating dialysis in DN patients, serum creatinine level was relatively low（659.036±350.533 μmol/L vs. 877.452±386.593μmol/L, t=3.789, P〈0.001）, anemia was relatively severe（86.839 ± 18.890 g/L vs. 93.092 ± 22.795 g/L, t=2.064, P=0.041）, serum phosphorus（1.648 ± 0.481 mmol/L vs. 2.006 ± 0.753 mmol/L, t=3.865, P〈0.001） and i PTH（236.150 ± 203.332 pg/ml vs.460.647 ± 480.166 pg/ml, t=2.766, P=0.007） were relatively low, and metabolic acidosis was not very heavy（t=-2.483, P=0.014）. The direct cause to initiate hemodialysis was mainly heart failure/edema in DN group and uremic symptoms in non-DN group. In the second 10-year period, blood urea nitrogen（30.427 ± 14.519mmol/L vs. 24.865±7.517 mmol/L, t=-1.312, P=0.036） increased significantly in all patients, but serum potassium（4.676 ± 0.945 mmol/L vs. 5.200 ± 0.745 mmol/L, t=1.880, P=0.037）, calcium（2.154 ± 0.369 mmol/L vs.2.395±0.270 mmol/L, t=2.033, P=0.037）, and i PTH（399.920±435.836 pg/ml vs. 968.000±705.377 pg/ml, t=2.399, P=0.020） were controlled better than those in the first 10 year period. Most patients initiated hemodialysis with central venous catheterization as the blood access. The proportion of arteriovenous fistula（AVF） for blood access had no significant change. Conclusions The leading primary disease of MHD was glomerulonephritis in our center, but the proportion of DN as the primary disease increased significantly in recent 10 years. DN patients initiated MHD earlier and often due to the refractory heart failure/edema. Controlling of chronic kidney disease complications became better in the recent 10 years. We should carefully take account of the appropriate time to create and the use of AVF in CKD patients.