生物电阻抗分析法评估容量超负荷对腹膜透析患者营养状况的影响

Evaluation of the effect of volume overload on nutritional status of peritoneal dialysis patients by bioelectric impedance analysis

目的探讨腹膜透析患者容量超负荷对营养状况的影响。方法选取进行居家腹膜透析且时间超过3个月的患者81例为研究对象。采集患者人口学资料,检测生化指标、评估患者腹膜透析充分性,利用多频生物电阻抗分析仪测定患者的容量负荷状态,根据浮肿指数[细胞外液量/身体总水量(ECW/TBW)]将患者分为容量正常组(ECW/TBW<0.400,A组,n=21)以及容量超负荷组(ECW/TBW≥0.400)。后者根据浮肿指数分为4组:0.400～0.410(B组,n=18)、0.411～0.420(C组,n=14)、0.421～0.430(D组,n=14)、0.431～0.440(E组,n=14)。比较各组患者的体质量增加量、24 h尿量、24 h腹透液超滤量、血压、24 h腹透液蛋白丢失量、血清白蛋白、超敏C反应蛋白、血糖、铁蛋白、血红蛋白、血肌酐、尿素清除指数(Kt/V)等。采用主观全面营养评估(SGA)方法对患者的营养状况进行评价,比较各组营养不良发生率。结果容量超负荷组与容量正常组患者间体质量增加量、24 h腹透液超滤量、24 h尿量、血压、24 h腹透液蛋白丢失量、血糖、血清白蛋白水平、超敏C反应蛋白水平、铁蛋白、血红蛋白、血肌酐、甲状旁腺激素(PTH)、血钙、血磷、Kt/V及营养不良发生率的差异均有统计学意义(P<0.05)。容量超负荷4组患者体质量增加量、24 h腹透液蛋白丢失量、血压、血糖、超敏C反应蛋白水平及营养不良发生率随着浮肿指数升高而升高,差异均有统计学意义(P<0.05);容量超负荷4组患者24 h尿量、24 h腹透液超滤量、血清白蛋白、铁蛋白、血红蛋白、血肌酐、甲状旁腺激素(PTH)、血钙、血磷及Kt/V水平随着浮肿指数升高而降低,差异有统计学意义(P<0.05)。结论容量超负荷的腹膜透析患者体质增加量较多、24 h腹透液超滤量减少、24 h尿量减少、血肌酐值较低、Kt/V水平不达标;而血压增高、血糖升高、24 h腹膜透出液蛋白丢失多、超敏C反应蛋白升高;以及血清白蛋白、铁蛋白、血红蛋白、PTH、血钙及血磷等营养状况指标恶化等可能是导致营养不良的原因,提示严格控制容量负荷可以改善患者营养不良状态。

Objective To study the effect of volume overload on nutritional status in peritoneal dialysis Patients.Methods All the 81 patients from the Dialysis Center at the Center Hospital Affiliated of Shenyang Medical College were enrolled from October 1,2015 to September 31,2017.The patients accepted peritoneal dialysis at home more than three months.The demographic data,biochemical data,sufficiency and fluid status were studied by multifrequency bioelectrical impedance analyzer.The participants were divided into normal volume group(ECW/TBW<0.400)and volume overload group(ECW/TBW≥0.400)according to swelling index(extracellular water/total body water:ECW/TBW).The latter group were subdivided into four groups,0.400-0.410,0.411-0.420,0.421-0.430 and 0.431-0.440 groups.The body quality increasing,urine volume,fluid ultrafiltration volume,blood pressure,protein loss from peritoneal dialysis in 24 hours,serum albumin,hypersensitive C-reactive protein,blood sugar,ferritin,hemoglobin,serum creatinine,Kt/V,etc.were analyzed among the groups.Subjective comprehensive nutrition assessment(SGA)was used to evaluate the nutritional status,and the incidence of malnutrition in each group was compared.Results There were 33 males and 48 females.The median age was 63.00 years and the median dialysis age was 26 months.The differences in age(P=0.135),gender(P=0.268),dialysis age(P=0.084)and serum potassium(P=0.239)between the normal and overloaded groups were not statistically significant.There were significant differences in body quality increase,24-hour ultrafiltration volume,24-hour urine protein,blood pressure,24-hour protein loss from dialysis,blood glucose,serum albumin level,hypersensitive C-reactive protein,ferritin,hemoglobin,serum creatinine,blood PTH,blood calcium,phosphorus,Kt/V and the incidence of malnutrition between the volume overload and normal group(P<0.05).Conclusion Patients with volume overload have more increase in body mass,less 24-hour peritoneal fluid ultrafiltration,less 24-hour urine volume,lower blood creatinine value and lower Kt/V level;while with increased blood pressure,blood glucose,fluid 24-hour protein loss in peritoneal membrane,and hypersensitive c-reactive protein.The deterioration of serum albumin,iron protein,hemoglobin,PTH,calcium and phosphorus may be the cause of malnutrition.It is suggested that strict control of capacity load can improve the malnutrition status of these patients.