腹膜透析与血液透析患者血清钙磷及甲状旁腺激素水平控制及其影响因素的对比研究

Comparison of control status and influencing factors of serum calcium,phosphorous and parathyroid hormone between peritoneal and hemodialysis patients

目的对比血液透析及腹膜透析患者钙磷及甲状旁腺激素水平控制情况并分析相关影响因素。方法单中心横断面观察研究纳入2013年3月至2015年3月在我院接受规律维持性透析治疗3个月以上、临床状况稳定的患者。收集患者临床资料,分析比较不同透析方式的患者血钙、血磷、全段甲状旁腺激素(intact parathyroid hormone,iPTH)达标率及相关影响因素。结果(1)共纳入患者448例,其中持续非卧床腹膜透析(continuous ambulatory peritoneal dialysis,CAPD)患者355例,间歇性血液透析(intermittent hemodialysis,IHD)患者93例。CAPD患者,男性182例(51.5%),平均年龄52.9岁,中位透析龄17.7个月,其中糖尿病肾脏病76例(21.4%)。IHD患者,男性55例(59.1%),平均年龄52.1岁,中位透析龄21.1个月,糖尿病肾脏病18例(19.3%)。(2)CAPD组和IHD组患者的血清校正钙达标率分别为65.7%、65.6%(P=0.99);血清磷达标率分别为53.2%、32.3%(P=0.31);iPTH达标率分别为47.3%、53.8%(P=0.30)。(3)IHD患者低钙血症的发生率明显高于CAPD患者(17.2%比2.8%,P<0.01),高磷血症的发生率也高于CAPD患者(59.1%比43.1%,P<0.01);CAPD患者的高钙血症明显高于IHD患者(31.5%比17.2%,P<0.01)。(4)不同透析患者钙、磷、iPTH不达标的风险因素比较:对于CAPD组患者,高龄、较长的透析龄是血钙未达标的独立危险因素;未服用磷结合剂、残余肾功能的降低是血清磷未达标的独立危险因素;高龄、较长的透析龄、高血磷是iPTH未达标的独立危险因素。对于IHD组患者,高iPTH是血钙未达标的独立危险因素;高iPTH、未服用磷结合剂是血清磷未达标的独立危险因素;高血磷、低血红蛋白水平是iPTH未达标的独立危险因素。结论腹膜透析高钙血症发生率较高,而血液透析患者低钙、高磷的发生率较高。保护残余肾功能、降低血清磷水平、提高血红蛋白水平、规范服用磷结合剂可能有助于钙磷代谢紊乱的纠正,提高透析患者生存质量。

Objective To compare the control status and influencing factors of serum calcium,phosphorus and parathyroid hormone in peritoneal versus hemodialysis patients.Methods A single-center cross-sectional observational study was performed.A total of 448 patients on stable maintenance dialysis for over 3 months were recruited from March 2013 to March 2015.The sociodemographic profiles,biochemical parameters and dialysis related parameters were collected for comparing the target-attaining rates of calcium,phosphorus and iPTH and analyzing the influencing factors between peritoneal and hemodialysis patients.Results There were 355 continuous ambulatory peritoneal dialysis(CAPD)patients with an average age of 52 years and a median vintage of 17 months.And there were 93 intermittent hemodialysis(IHD)patients with an average age of 52 years and a median vintage of 21 months.Among CAPD patients,there were 182 males(51.5%)and 76 cases(21.4%)had a diagnosis of diabetic kidney disease.In IHD patients,55(59.1%)were males and 18(19.3%)diabetic kidney disease.The target-attaining rates of serum calcium,serum phosphate and iPTH were not statistically different between two groups(serum calcium:65.7%vs 65.6%,P=0.99;serum phosphate:53.2%vs 33.3%,P=0.31;iPTH:47.3%vs 53.8%,P=0.30).The incidence of hypocalcemia was significantly higher in IHD group than that in CAPD group(17.2%vs 2.8%,P<0.01)and hyperphosphatemia occurred more frequently in IHD group(9.1%vs 43.1%,P<0.01).And the incidence of hypercalcemia was higher in CAPD group than that in IHD group(31.5%vs 17.2%,P<0.01).Comparisons of risk factors for calcium,phosphorus and iPTH failure in different groups:For CAPD patients,advanced age and longer dialysis vintage were the independent risk factors for non-targeting of serum level of calcium.Taking no phosphate binder and impaired residual renal function were independently associated with non-targeting of serum phosphate level.Advanced age,longer dialysis vintage and a higher level of serum phosphate were the independent risk factors of non-targeting of iPTH level.For IHD patients,a higher level of iPTH was an independent risk factor for non-targeting of serum level of calcium.A higher level of iPTH and taking no phosphate binder were the independently associated with targeting of serum level of phosphate.A higher level of serum phosphate and a lower level of hemoglobin were the independent risk factors for non-targeting of iPTH level.Conclusion The incidence of hypocalcemia and hyperphosphatemia were significantly higher and the incidence of hypercalcemia was lower in IHD group than in CAPD group.Regular monitoring may facilitate controlling abnormal calcium-phosphorous metabolism and boost quality-of-life through protecting residual renal function,reducing serum phosphorus level,enhancing hemoglobin level and rationalizing phosphorus binder.