钙磷代谢对于维持性腹膜透析患者心力衰竭的影响研究

The effects of calcium and phosphorus metabolism on heart failure of maintenance peritoneal dialysis patients

目的探讨钙磷代谢相关指标对维持性腹膜透析患者心力衰竭患病影响以及风险预测作用。方法本研究为回顾性多中心临床研究。选取2014年01月~2018年10月在上海市交通大学附属第六人民医院集团行维持性腹膜透析(maintenance peritoneal dialysis,MPD)的患者322例。通过空腹血清磷水平,将患者分为高磷组143例(血磷≥1.6 mmol/L),低磷组21例(血磷≤0.8mmol/L),正常组磷158例(0.8mmol/L<血磷<1.6mmol/L),随访大于3个月,记录心力衰竭事件的发生。首先,分析组间一般情况、透析指标、理化结果和心脏彩超参数的差异;其次,我们分析心力衰竭患病与钙磷代谢及其它临床指标的关系;最后,我们采用Kaplan-Meier曲线评估钙磷代谢对于心力衰竭发生生存分析,应用多元logistic回归模型评估心力衰竭患病风险。所有统计采用SPSS 20.0软件分析,P<0.05表示差异显著。结果①在随访期间[(25.46±16.98)月]共发生心力衰竭事件179例。高磷组心力衰竭患病率(69.2%)高于低磷组(4.8%)和正常磷组(50.0%),F=17.386,P=0.016。②高磷组、低磷组、正常组3组在透析龄(F=202.706,P=0.009)、白蛋白水平(F=84.193,P=0.020)方面比较差异有统计学意义。③应用Kaplan-Meier曲线评估钙磷代谢对于心力衰竭发生的生存分析,发现在MPD人群中,低钙高磷高全段甲状旁腺素(intact parathyroid hormone,iPTH)的患者发生心力衰竭的风险更大(P=0.002)。④多因素logistic回归分析显示,高血磷、高iPTH均是腹膜透析患者心力衰竭患病的高危因素,风险OR、95%CI分别为1.231(1.023~4.634,P=0.004)、1.003(1.000~1.006,P=0.030)。结论高磷、高iPTH是维持性腹膜透析患者发生心力衰竭的独立危险因素,低钙高磷高iPTH的维持性腹膜透析患者发生心力衰竭的风险更大。因此,纠正维持性腹膜透析患者钙磷代谢紊乱对减少心力衰竭的发生具有重要意义。

Objective To investigate the levels of serum calcium, serum phosphorus and iPTH to influence and predict the heart failure(HF) in maintenance peritoneal dialysis(MPD) patients. Methods A total of 322 MPD patients treated in our hospitals from January 2014 to October 2018 were recruited in this retrospective and multicenter clinical study. Based on morning fasting serum phosphate level(Pi), patients were divided into high phosphorus group(Pi≥1.6 mmol/L, n=143), low phosphorus group(Pi ≤0.8 mmol/L, n=21) and normal phosphorus group(0.8 mmol/L< Pi <1.6 mmol/L, n=158). They were followed up for more than 3 months, and the presence of HF events was recorded. Clinical data, peritoneal dialysis indices, laboratory examinations and echocardiographic parameters were compared between the 3 groups. The correlation of calcium/phosphorus metabolism and other clinical parameters with HF was analyzed. The effect of calcium/phosphorus metabolism on survival of the MPD patients with HF was assessed by Kaplan-Meier curve method.Multivariate logistic regression model was used to evaluate the risk factors for HF in MPD patients. SPSS20.0 was used for the statistical analyses, and P<0.05 was considered to be statistically significant. Results ①HF was found in 179 cases within the follow-up period of 25.46±16.98 months. The prevalence of HF was higher in high phosphorus group(69.2%) than in low phosphorus group(4.8%) and normal phosphorus group(50.0%)(F=17.386, P=0.016).②There were statistical differences in dialysis age(F=202.706, P=0.009) and serum albumin(F=84.193, P=0.020) between the 3 groups.③ Kaplan-Meier curve method revealed that MPD patients with low calcium, high phosphorus and high iPTH were at high risk of HF(P=0.002).④ Multivariate logistic regression model found that higher serum phosphorus and iPTH were the risk factors for HF in MPD patients(OR=1.231 and 1.003 respectively;95% CI=1.023~4.634 and 1.000~1.006 respectively;P=0.004 and 0.030 respectively). Conclusions Higher levels of serum phosphorus and iPTH are the independent risk factors for HF in MPD patients, and MPD patients with lower serum calcium accompanied by higher levels of phosphorus and higher iPTH will have higher risk of HF. Therefore, treatment for the disorders of calcium and phosphorus metabolism is an essential method for the prevention of HF in MPD patients.