维持性血液透析患者甲状腺激素的异常及其对生存的影响

Effect of serum thyroid hormone abnormalities on survival in patients undergoing maintenance hemodialysis

目的探讨维持性血液透析(maintenance hemodialysis,MHD)患者甲状腺激素异常的临床特点及其对生存的影响。方法收集2011年11月~2016年11月在北京大学第三医院进行MHD患者的人口学、甲状腺功能及临床生化等资料,并随访5年。将患者分为正常甲状腺功能、低三碘甲状腺原氨酸(triiodothyronine,T3)综合征、甲状腺机能减退症(以下简称甲减症)等3组,通过单因素方差分析比较其特点,采用多元线性回归来探讨影响血清游离T3(free triiodothyronine,FT3)的因素,基于COX比例风险模型分析血清甲状腺激素对患者生存的影响。结果本研究共纳入研究对象121例,其中表现为低T3综合征者78例(64.50%),甲减症者15例(12.40%)。与正常组相比,低T3综合征及甲减症组女性比例更高(χ2=10.082,P=0.006)、年龄更大(F=4.899,P=0.009),而体质量、血清前白蛋白(prealbumin,PAB)水平更低(F值分别为4.129,6.233;P值分别为0.019,0.003)。多元线性回归分析提示血清CRP和PAB是影响血清FT3水平的独立因素(β值分别为-0.266,0.250;P值分别为0.004,0.022)。COX比例风险模型显示在校正性别、年龄、糖尿病、透析龄以及血红蛋白等因素后,血清FT3仍能独立地影响患者生存(HR 0.343,95%CI 0.130~0.906,P=0.031),而TSH却不能(HR 0.997,95%CI 0.969~1.026,P=0.831)。结论MHD患者的甲状腺功能紊乱主要表现为低T3综合征,血清FT3而非TSH能独立地预测患者的全因死亡。

Objective To examine the changes of serum thyroid hormones and their effect on survival in patients undergoing maintenance hemodialysis dialysis(MHD).Methods Baseline data including demographic information,thyroid hormone tests,and clinical biochemistry were collected from MHD patients treated in Peking University Third Hospital in November 2011 and a fivEyear follow-up was then performed.The patients were divided into three groups:euthyroid,low triiodothyronine(T3)syndrome,and hypothyroidism.OnEway ANOVA was used to compare the differences among groups.Multivariate regression analysis was performed to examine the affecting factors for serum free T3(FT3).Cox proportional hazards modeling was used to analyze the association between serum thyroid hormones and all-cause mortality.Results A total of 121 patients were included in this study,of whom 78(64.50%)had low T3 syndrome and 15(12.40%)had hypothyroidism.In patients in low T3 syndrome group or hypothyroidism group,the proportion of female(χ2=10.082,P=0.006)and older age(F=4.899,P=0.009)were higher but body weight(F=4.129,P=0.019)and serum prealbumin(F=6.233,P=0.003)were lower,as compared with those in euthyroid group.Multivariate regression analysis showed that serum CRP and prealbumin were the independent influence factors on serum FT3 level(β=-0.266,P=0.004;β=0.250,P=0.022).COX regression analysis showed that serum FT3 was an independent risk factor for death in MHD patients(HR 0.343,95%CI 0.130~0.906;P=0.031)but TSH was not the risk factor(HR 0.997,95%CI 0.969~1.026;P=0.831)after adjusting sex,age,diabetes mellitus,dialysis vintage and hemoglobin.Conclusions Our study indicates that low T3 syndrome is a dominant modality of thyroid dysfunction,and serum FT3 but not TSH can independently predict the all-cause mortality in MHD patients.