代谢综合征对腹膜透析患者预后的影响

Metabolic syndrome in peritoneal dialysis patients： choice of diagnostic criteria and prognosis

目的探讨代谢综合征（MS）对腹膜透析（腹透）患者长期生存、心血管疾病预后的影响，及适合于腹透患者的MS诊断标准。方法本研究为前瞻性队列研究，病例来自2008年10月至2009年3月北京大学第三医院肾内科的腹透患者258例。分别按照世界卫生组织（WHO）、美国国家胆固醇教育项目成人治疗指南（NCEPATPII，ATP）和国际糖尿病联盟（IDF）诊断标准将入组患者分为MS组和无MS组。中位随访时间51．9（26．8，97．9）个月。用Kaplan—Meier（Log-rank检验）生存曲线法比较MS组和无MS组患者累积生存率的差异；并分析比较非糖尿病肾病亚组患者累积生存率的差异。用Cox回归分析影响腹透患者长期生存的独立危险因素。结果258例腹透患者中，WHO标准诊断的MS组患者106例（41．1％）；IDF标准121例（46．9％）；ATP标准167例（64．7％）。至随访终点死亡患者139例，死于心脑血管疾病者50例（36．0％）。以WHO和IDF标准诊断的MS组患者累积生存率明显低于非MS组患者（WHO标准：21．3％比44．8％；IDF标准：23．3％比45．7％，均P〈0．01）；非糖尿病肾病亚组也得出相似的结果（均Pc0．05）。以心血管疾病死亡为终点事件进行生存分析，WHO和IDF诊断标准下MS组比非MS组的累积生存率均明显降低（均P〈0．05）；非糖尿病肾病亚组中只有IDF标准下两组累积生存率的差异有统计学意义（P〈0．05）。多因素Cox回归分析结果显示，代谢综合征和血白蛋白是腹透患者全因死亡和心血管疾病死亡的独立危险因素（均P〈0．01）。腰围、血糖、血低密度脂蛋白胆固醇（LDL-C）水平是腹透患者全因死亡的危险因素（均P〈0．01）。结论代谢综合征是腹膜透析患者全因死亡、心血管疾病死亡的独立危险因素，腰围、血糖和血LDL-C是其中的重要影响因素。推荐在腹透患者中使用IDF标准诊断MS。

Objectives To investigate whether the presence of metabolic syndrome （MS） modifies overall survival and cardiovascular （CV） outcomes among patients undergoing long- term peritoneal dialysis （PD） and to explore suitable diagnostic criterion for PD patients. Methods A total of 258 patients on PD in Peking University Third Hospital between October 2008 and March 2009 were enrolled and followed until June 2017. According to the diagnostic criteria of WHO, IDF and ATP m, the patients were divided into MS group and non-MS group. The median following time was 51.9 （26.8, 97.9） months. Overall survival and cardiovascular death were analyzed by the Kaplan- Meier method. The analyses were also done among non- diabetic PD patients. The influence of MS and its components on outcomes was analyzed by Cox regression models. Results Among 258 PD patients, 106（41.1%） fulfilled the WHO criteria, 121（46.9%） the IDF criteria, and 167（64.7%） the ATP criteria.139 cases were dead, among which 50（36.0%） cases were caused by CV diseases. The patients with MS had worse outcomes than those without MS by WHO and IDF criteria （cumulative survival rates of WHO criteria： 21.3% vs 44.8%, P 〈 0.01; cumulative surviva rats of IDF criteria： 23.3% vs 45.7%, P 〈 0.01）. It was the same even in non-diabetic PD patients. The patients with MS had more CV death than those without MS by WHO and IDF criteria （both P 〈 0.05）. Among non-diabetic PD patients, the results remained the same only by IDF criteria （P 〈 0.05）. By ATP criteria, above analyses showed no i difference. By multivariate Cox regression analysis, MS and serum albumin （all P 〈 0.01） were independently associated with increased risk for overall and cardiovascular survival. Among MS components, waist girth, low-density lipoprotein cholesterol （LDL-C） levels and blood sugar （all P 〈 0.01） were significant risk factors for adverse survival outcomes. Conclusions In patients undergoing PD, both overall survival and cardiovascular survival were worse in patients with MS than those without MS. Waist girth, blood sugar and serum LDL- C were the main risk factors. For PD patients the IDF criterion for MS was recommended.