透析前慢性肾脏病门诊管理对维持性血液透析患者的益处

The advantages of pre-dialysis management in chronic kidney disease outpatient clinic in maintenance hemodialysis patients

目的评价透析前慢性肾脏病(chronic kidney disease,CKD)门诊管理对维持性血液透析患者的益处,为更好的开展慢性肾脏病门诊管理工作提供依据。方法采用单中心回顾性研究,纳入江苏大学附属医院慢性肾脏病管理门诊患者中2015年3月~2017年6月进入透析的39例患者(管理组)及同时期在我科血液净化中心新进入透析的142例患者(非管理组),比较了两组之间的透析通路及进入透析时实验室指标的差异。结果共181例患者纳入本研究,平均年龄(60.6±15.3)岁,男性111例(占61.3%),进入血液透析时,两组患者的性别、年龄、原发病构成、合并症等均无统计学差异。进入血液透析时管理组的血压要优于非管理组[(146.1±14.2)mm Hg对比(160.3±28.8)mm Hg,t=4.297,P<0.001],血红蛋白明显高于非管理组[(88.8±17.2)g/L对比(75.5±17.3)g/L,t=-4.253,P<0.001],e GFR(estimated glomerular filtrationrate,e GFR)高于非管理组[(7.0±2.3)ml/min对比(5.5±3.1)ml/min,t=0.906,P=0.020],血磷[(1.7±0.4)mmol/L对比(2.0±0.6)mmol/L,t=3.486,P=0.010]和全段甲状旁腺激素水平(intact parathyroid hormone,i PTH)[(270.7±157.1)pg/ml对比(342.7±286.4)pg/ml,t=2.070,P=0.040]都低于非管理组。启动首次血液透析时,非管理组仅有5例(3.5%)患者使用动静脉内瘘(arteriovenous fistula,AVF),137例(96.5%)患者使用中心静脉导管(central venous catheter,CVC)。而管理组有29例(74.4%)患者使用AVF,2例(5.1%)患者使用带隧道带cuff导管,仅有8例(20.5%)患者使用CVC,两组在血管通路比较上有显著统计学差异(χ2=110.815,P<0.001)。结论透析前的慢性肾脏病门诊管理能明显改善患者进入透析时的血压、贫血、肾性骨病的情况,更好的把握患者进入透析的时机。在血管通路方面,大大提高了计划性通路建立的比例,明显降低了临时插管的比例。

Objective To evaluate the advantages of pre-dialysis management in chronic kidney disease（CKD） outpatient clinic in maintenance hemodialysis（MHD） patients and to provide the bases for CKD patient treatment in outpatient clinic. Methods This was a retrospective single center study, which enrolled 39 initial hemodialysis patients managed in our CKD outpatient clinic（management group, group M） and 142 initial hemodialysis patients without management in CKD outpatient clinic（non-management group, group NM）in the period from March 2015 to June 2017. Their vascular access methods and laboratory indices at the beginning of hemodialysis were compared. Results A total of 181 patients were enrolled in this study. The mean age was 60.6±15.3 years and 111 patients（61.3%） were male. There were no significant differences in gender, age, cause of CKD, and comorbidities between the two groups. At the initiation of hemodialysis, lower blood pressure [（146.1±14.2） mmHg vs.（160.3±28.8） mmHg, t=4.297, P〈0.001）, serum phosphorus [（1.7±0.4） mmol/L vs.（2.0±0.6） ml/min, t=3.486, P=0.010] and i PTH [（270.7±157.1） pg/ml vs.（342.7±286.4） pg/ml, t=2.070, P=0.040], and higher hemoglobin [（88.8±17.2） g/L vs.（75.5±17.3） g/L, t=-4.253, P〈0.001] and eGFR [（7.0±2.3） ml/min vs.（5.5±3.1） ml/min, t=0.906, P =0.020] were found in group M as compared with those in group NM. Five patients（3.5%） used arteriovenous fistula（AVF） and 137（96.5%） patients used central venous catheter（CVC） as the blood access in group NM, while 29 patients（74.4%） used AVF, 2 patients（5.1%） used tunneled cuffed catheter and 8 patients（20.5%） used CVC as the blood access in group M. The blood access methods were significantly different between the two groups（χ^2=110.815, P〈0.001）. Conclusions Pre-dialysis management for CKD patients improved their blood pressure, anemia, and renal bone disease at the initiation of hemodialysis, resulting in a better status at the time when hemodialysis was initiated.Pre-dialysis management also increased the use of planned blood access methods and decreased the use of temporary catheterization for blood access.