不同钙离子浓度透析液对维持性血液透析患者微炎症状态、心肌损伤标志物和心脏结构及功能的影响

Effects of dialysates with different calcium concentration on microinflammation,myocardial damage markers,and cardiac structure and function in maintenance hemodialysis patients

目的:分析不同钙离子浓度透析液对维持性血液透析(MHD)患者微炎症状态、心肌损伤标志物和心脏结构及功能的影响。方法:选取2015-09-2018-10我院收治的93例MHD患者,简单随机化分为3组,每组各31例。dCa^2+ 1.25、1.5、1.75组分别采用1.25、1.5、1.75 mmol/L钙浓度进行血液透析,比较3组患者微炎症状态指标[C-反应蛋白(CRP)、白细胞介素-6(IL-6)、白细胞介素-8(IL-8)、肿瘤坏死因子-α(TNF-α)]、心肌损伤标志物[B型脑钠肽(BNP)、心肌肌钙蛋白T(cTnT)、同型半胱氨酸(Hcy)、肌酸激酶同工酶(CK-MB)]、心脏结构及功能指标[左室间隔厚度(IVST)、左心室等容舒张期时间(IVRT)、左心室舒张末期内径(LVEDD)、射血分数(EF)、左心室后壁厚度(LVPWT)、短轴缩短分数(FS)、左心室收缩末期内径(LVESD)、舒张早期最大血流速与舒张晚期最大血流速之比(E/Amax)]以及并发症发生情况。结果:dCa^2+ 1.25组透析后血清CRP、IL-6、IL-8、TNF-α均较透析前降低(均P<0.05);dCa^2+ 1.5组透析前后血清CRP、IL-6、IL-8、TNF-α比较,差异无统计学意义;dCa^2+ 1.75组透析后血清CRP、IL-6、IL-8、TNF-α均较透析前升高(均P<0.05);dCa^2+ 1.25组、dCa^2+ 1.5组、dCa^2+ 1.75组透析后血清CRP、IL-6、IL-8、TNF-α水平依次呈升高趋势(P<0.05);3组透析后血清BNP、cTnT、Hcy、CK-MB水平均较透析前降低,且dCa^2+ 1.25组、dCa^2+ 1.5组、dCa^2+ 1.75组依次升高(P<0.05);3组透析后IVRT均较透析前增大,且dCa^2+ 1.25组、dCa^2+ 1.5组、dCa^2+ 1.75组依次增大(P<0.05);dCa^2+ 1.75组透析后E/Amax较透析前降低(P<0.05);dCa^2+ 1.5组血钙异常(3.23%)、血磷异常率(6.45%)均低于dCa^2+ 1.25组(29.03%、32.26%)、dCa^2+ 1.75组(32.26%、25.81%)(均P<0.05)。结论:低钙离子浓度透析液可改善MHD患者微炎症状态,保护心肌细胞,且不影响心脏结构,但应密切监测血钙、血磷水平,以指导临床实施针对性干预,最大化患者受益。

Objective:To analyze the effects of dialysates with different calcium concentration on microinflammation,myocardial damage markers and cardiac structure and function in maintenance hemodialysis(MHD)patients.Method:From September 2015 to October 2018,93 patients with MHD admitted to our hospital were randomized into three groups,31 cases in each group.Groups of dCa^2+1.25,1.5 and 1.75 were treated with 1.25,1.5 and 1.75 mmol/L calcium concentration for hemodialysis,respectively.The microinflammatory state indexes[C-reactive protein(CRP),interleukin-6(IL-6),interleukin-8(IL-8),tumor necrosis factor-α(TNF-α)],myocardial injury markers[B-type brain natriuretic peptide(BNP),cardiac troponin T(cTnT),homocysteine(Hcy),creatine kinase isoenzymes(CK-MB)],cardiac structural and functional indexes[left ventricular septal thickness(IVST),left ventricular isovolumic diastolic time(IVRT),left ventricular end-diastolic diameter(LVEDD),ejection fraction(EF),left ventricular posterior wall thickness(LVPWT),short axis fraction(FS),left ventricular end-systolic diameter(LVESD),maximum blood flow rate and diastolic rate in early diastolic phase,late maximum blood flow velocity ratio(E/Amax)]and complications were compared among the three groups.Result:The levels of serum CRP,IL-6,IL-8 and TNF-αafter dialysis all were lower than those before dialysis in dCa^2+1.25 group(all P<0.05).The levels of CRP,IL-6,IL-8 and TNF-αbefore and after dialysis were not significantly different in dCa^2+1.5 group.The levels of CRP,IL-6,IL-8 and TNF-αafter dialysis were higher than those before dialysis in dCa^2+1.75 group(all P<0.05).The levels of serum CRP,IL-6,IL-8 and TNF-αafter dialysis in dCa^2+1.25 group,dCa^2+1.5 group and dCa^2+1.75 group increased gradually(all P<0.05).The levels of serum BNP,cTnT,Hcy and CK-MB after dialysis were lower than those before dialysis in three groups and increased gradually in dCa^2+1.25 group,dCa^2+1.5 group and dCa^2+1.75 group(all P<0.05).The levels of IVRT were higher than those before dialysis in three groups and increased gradually in dCa^2+1.25 group,dCa^2+1.5 group and dCa^2+1.75 group(all P<0.05).The level of E/Amax after dialysis was lower than that before dialysis in dCa^2+1.75 group(P<0.05).Abnormal calcium(3.23%)and phosphorus(6.45%)in dCa^2+1.5 group were lower than those in dCa^2+1.25 group(29.03%,32.26%)and dCa^2+1.75 group(32.26%,25.81%)(all P<0.05).Conclusion:Low calcium concentration dialysate can improve microinflammation and protect myocardial cells in MHD patients without affecting cardiac structure,but blood calcium and phosphorus levels should be closely monitored to guide clinical intervention and maximize the benefits of patients.