腹膜透析患者的远期预后及影响因素

Long-term prognosis and risk factors of peritoneal dialysis patients:a cohort of 245 patients

目的:分析腹膜透析(PD)患者的临床资料、转归及影响远期预后的因素。方法:收集常熟市第一人民医院2008年1月至2018年12月245例PD患者的临床资料,分析患者生存率及技术存活率、退出PD患者的治疗时间(TOT)及掉队率(OOR),并根据随访结局分成死亡组和存活组。比较两组患者的特点,探讨影响死亡的危险因素。结果:男性155例(63.3%),女性90例(36.7%),平均年龄(56.3±14.4)岁,平均透程(23.3±18.8)月。原发病中原发性肾小球肾炎164例(66.9%),糖尿病肾病59例(24.1%)。至2018年12月底,维持PD 124例(50.6%),死亡64例(26.1%),转为血液透析25例(10.2%),肾移植19例(7.8%),PD联合血液透析9例(3.7%),失访4例(1.6%)。近五年退出PD患者的TOT为25.4月,历年TOT呈上升趋势。近五年DOR总体呈下降趋势,2018年为25.9%。死亡原因中心血管事件排首位(53.1%),其次脑血管事件(23.4%),感染(18.7%)占第3位(包括肺部感染和腹膜炎)。转为血液透析最主要原因为腹膜炎(40.0%),其次为心力衰竭(32.0%)和透析不充分(20.0%)。死亡组年龄、糖尿病肾病比例高于存活组(P<0.05),透程及置管前白蛋白、前白蛋白、血清肌酐(SCr)、β2微球蛋白、磷均低于存活组。1年、3年、5年患者生存率依次为89.0%、67.7%、56.6%,技术存活率分别为90.7%、81.1%、64.4%。Logistic分析提示开始PD时的年龄(OR 1.199,95%CI 1.093~1.316,P=0.000)、SCr(OR 1.004,95%CI 1.000~1.008,P=0.030)、前白蛋白(OR 0.986,95%CI 0.975~0.998,P=0.021)是PD患者死亡的独立风险因素。结论:患者退出的主要原因是死亡和转为血液透析。心脑血管事件和感染是主要死因,腹膜炎是转为血液透析首要原因。开始PD时的年龄、SCr水平、前白蛋白水平是影响患者死亡的危险因素。积极控制感染、改善营养状态可改善PD患者的生存,尤其需关注老年糖尿病肾病患者。

Objective:To analyze the clinical features,outcomes and risk factors of peritoneal dialysis(PD) patients in our hospital. Methodology:Clinical data of 245 PD patients treated in our hospital from Jan 2008 to Dec 2018 were collected,the patients survival rate,technical survival rate time on therapy(TOT) and drop out rate(DOR) were analyzed.According to the outcome,patients were divided into death group and survival group,and the characteristics between the two groups were compared. Results:155(63.3%) were males, the mean age at the beginning of PD was(56.3±14.4) years, and the mean PD duration was(23.3±18.8) months.Chronic glomerulonephritis(66.9%) was the most common primary disease, followed by diabetes mellitus(24.1%).Up to Dec 2018,the patients remained on PD in 124 cases(50.6%),64 cases(26.1%) died,changed to hemodialysis(HD) in 25 cases(10.2%),treated with kidney transplant in 19 cases(7.8%),combination theraphy with PD and HD in 9 cases(3.7%),and dropped out of our follow-up in 4 cases(1.6%).TOT increased gradually with year and was 25.4 months in 2018.DOR decreased gradually and was 25.9% in 2018.The main cause of death was cardiovascular events(53.1%), followed by cerebrovascular events(23.4%) and infection(18.7%). Compared to the survivals, patients in the mortality group seemed to have greater popularity of diabetes, but lower levels of albumin, prealbumin, serum creatinine, β2-MG and phosphorus, and were much more older.The patient survival rates at 1,3,5 years were 89.0%、67.7%、56.6%,respectively,technique survival rates at 1,3,5 years were 90.7%、81.1%、64.4%.The predictors of patient’s death in this study were age(OR 1.199,95%CI 1.093~1.316,P=0.000),serum creatine(OR 1.004,95%CI 1.000~1.008,P=0.030) and prealbumin(OR 0.986,95%CI 0.975~0.998,P=0.021). Conclusion:The major cause of dropout from PD was death,followed by the transfer to hemodialysis.Cardiovascular event was the most important cause of death,and peritonitis was the major reason for the change from PD to HD.Patients with older age, hypoprealbuminemia and diabetes were associated with poor outcomes.