老年血液透析患者红细胞体积分布宽度水平及相关影响因素分析

Influence factors analysis of red blood cell distribution width in elderly hemodialysis patients

目的:探讨老年血液透析患者红细胞体积分布宽度(red cell distribution width,RDW)水平及其临床意义。方法:前瞻性入选2017年7月至12月在上海市健康医学院附属嘉定区中心医院血液净化中心维持性透析老年患者128例。其中男性48例,女性80例,年龄(69.2±4.5)岁,透析龄(64.3±42.5)个月。所有患者均收集临床病史,并于周中透析前检测血红蛋白、红细胞体积分布宽度、电解质、高敏C反应蛋白、血清白蛋白、铁蛋白、甲状旁腺素等临床指标。应用Pearson相关分析和多元线性逐步回归模型分析各临床指标与RDW的关系。应用曲线拟合模型分析可能与RDW呈非线性相关的临床指标。所有患者临床随访12个月,主要终点为死亡,次要终点为各类型心脑血管事件。应用Kaplan-Meier法分析RDW高值组和低值组患者上述终点事件的差异。应用Cox比例风险模型分析与预后相关的独立预测因子。结果:整组患者RDW为[(16.24±2.22)%,(14.0~20.4)%],中位数15.1%,105(82.1%)例患者RDW水平超过参考值上限。男性患者RDW水平低于女性患者组。Pearson相关分析提示RDW与透析龄、每周促进细胞生成素(EPO)剂量、高敏C反应蛋白、透析间期体质量增加比例显著正相关。RDW与血清白蛋白显著负相关。多元线性逐步回归模型结果提示RDW与血清白蛋白显著负相关(P<0.01),与每周EPO剂量显著正相关(P<0.01)。RDW与血红蛋白呈曲线相关,以二次方程拟合优度最佳(P<0.001)。全部患者均随访12个月,共死亡6例,其中RDW高值组4例,RDW低值组2例,差异无统计学意义。随访期间发生各类心脑血管事件36例,其中RDW高值组26例,RDW低值组10例。Kaplan-Meier分析提示RDW高值组和RDW低值组患者在12个月随访期内心脑血管事件发生率差异有统计学意义(log-rank=16.224,P<0.001)。单因素Cox回归显示RDW水平与12个月内心脑血管事件正相关,血红蛋白、血清白蛋白和12个月内心脑血管事件负相关。多因素Cox回归结果显示RDW(HR=1.231,P=0.015)、血清白蛋白水平(HR=0.964,P<0.001)是老年维持性血液透析患者12个月内心脑血管事件的独立预测因素。结论:老年血液透析患者中RDW水平普遍增高,且与贫血、透析龄、营养水平、炎症状态、心脏功能、EPO剂量及反应等多项临床指标有关;RDW水平增高与老年维持性血液透析患者短期临床心脑血管事件转归相关。

Objective:To investigate the level of red blood cell volume distribution width in aged hemodialysis patients and analyze the clinical significance.Methods:Totally,128 hemodialysis patients(48 males and 80 females)with mean age of(69.2±4.5)years old and mean dialysis vintage of(64.3±42.5)months from July 2017 to December 2017 were prospectively enrolled.Medical history was collected and parameters such as hemoglobin,red blood cell distribution width(RDW),serum electrolytes,high sensitivity C-reactive protein(hsCRP),serum albumin,ferritin,and intact parathyroid hormone(iPTH)were measured before the mid-week hemodialysis.Pearson correlation analysis and multiple linear stepwise regression model were applied to analyze the relationship between these clinical parameters and RDW.Curve fitting model was used to analyze the clinical parameters that may be non-linearly correlated with RDW.All patients were followed up for 12 months.The primary end point was death and the secondary end point was cardiovascular events.Survival analysis was performed with Kaplan-Meier survival curves between the higher RDW group and the lower RDW group.Cox proportional hazards model was used to explore independent predictors related to prognosis.Results:The mean RDW was([16.24±2.22]%,[14.0 to 20.4]%[median 15.1%])in all patients,of which 105(82.1%)were abnormal.Pearson correlation analysis showed that RDW was positively correlated with dialysis vintage,EPO dose,hsCRP,and interdialytic weight gain ratio.RDW was negatively correlated with serum albumin.Multivariate linear regression model showed that RDW was significantly associated with serum albumin and EPO dose(P<0.01).In curve fitting estimation,the quadratic equation had the goodness of fitting with statistical significance(P<0.001).A total of 6 patients died during the 12-month follow-up with 4 patients in the higher RDW group and 2 patients in the lower RDW group.There was no significant difference between the two groups.During the follow-up,36 cases of various cardiovascular and cerebrovascular events occurred in which 26 cases in the higher RDW group and 10 cases in the lower RDW group.Kaplan-Meier analysis indicated that there was a statistically significant difference in the incidence of cardiovascular events between the higher RDW group and the lower RDW group(log-rank=16.224,P<0.001).Univariate Cox regression showed that RDW level was positively correlated with cardiovascular and cerebrovascular events,while hemoglobin,serum albumin level were negatively correlated with cardiovascular and cerebrovascular events.Multivariate Cox regression model showed that RDW(HR=1.231,P=0.015)and serum albumin level(HR=0.964,P<0.001)were independent predictors of cardiovascular and cerebrovascular events in elderly hemodialysis patients within 12 months.Conclusions:Increased RDW was common in elderly hemodialysis patients,which might be related to anemia,dialysis age,nutritional status,inflammatory status,cardiac function,EPO dose and response.The increased RDW level was associated with clinical cardiovascular and cerebrovascular events in elderly hemodialysis patients.