利用血液透析滤过技术加强同型半胱氨酸清除对维持性血液透析患者认知功能障碍的治疗作用

Effect of enhancing homocysteine clearance by hemodiafiltration on cognitive impairment of maintenance hemodialysis patients

目的探讨血液透析滤过(HDF)对维持性血液透析(MHD)患者认知功能的影响。方法对符合入排标准的MHD患者进行认知功能和同型半胱氨酸(HCY)水平评价,分析与认知功能相关的危险因素。符合入排标准的70例中脱落25例,将余下的45例采用数字表法随机分为对照组(23例)和治疗组(22例)。对照组采用低流量血液透析(HD),治疗组给予HDF联合低流量HD。观察两组患者治疗前、治疗6个月、治疗12个月时认知功能、HCY水平等实验室指标。观察HCY清除率增高对认知功能的影响。结果认知功能与年龄(r=-0.371,P=0.002<0.05)和HCY水平(r=-0.612,P=0.000<0.05)呈负相关,与教育程度呈正相关(Spearman秩相关系数ρ=0.620,P<0.05),HCY是唯一的调节因子。两组患者性别、教育程度、原发病、年龄、透析龄及透析频率比较,差异均无统计学意义(P>0.05)。治疗前,两组各项实验室指标比较,差异均无统计学意义(P>0.05)。治疗6个月时,治疗组认知功能评分(21.64±4.25)分高于对照组的(18.09±4.67)分,HCY为(17.36±5.74)μmol/L、β2微球蛋白为(12.02±4.36)mg/L、胱抑素C为(3.72±0.66)mg/L均低于对照组的(23.96±5.08)μmol/L、(15.51±5.51)mg/L、(5.03±1.03)mg/L,差异有统计学意义(P<0.05)。治疗12个月时,治疗组认知功能评分(26.27±1.96)分高于对照组的(17.00±4.73)分,HCY为(11.28±3.48)μmol/L、β2微球蛋白为(7.99±2.66)mg/L、胱抑素C为(3.28±0.56)mg/L均低于对照组的(24.40±6.49)μmol/L、(16.14±4.89)mg/L、(4.99±1.21)mg/L,差异有统计学意义(P<0.05)。治疗12个月时,治疗组磷酸盐为(1.82±0.18)mmol/L、血肌酐为(793.82±141.23)μmol/L、血尿酸为(411.18±74.92)μmol/L、甲状旁腺素为(362.19±91.55)ng/L、舒张压为(79.99±9.37)mm Hg(1 mm Hg=0.133 kPa)均低于对照组的(2.34±0.29)mmol/L、(938.95±205.38)μmol/L、(450.30±53.04)μmol/L、(459.61±131.95)ng/L、(87.39±14.51)mm Hg,差异有统计学意义(P<0.05)。在治疗6个月时治疗组HCY、β2微球蛋白、胱抑素C水平低于本组治疗前,差异有统计学意义(P<0.05)。在治疗12个月时治疗组认知功能评分高于本组治疗前,HCY、磷酸盐、血肌酐、β2微球蛋白、胱抑素C、舒张压、甲状旁腺素水平均低于本组治疗前,差异有统计学意义(P<0.05)。对照组各项实验室指标与本组治疗前比较,差异均无统计学意义(P>0.05)。结论HDF可加强HCY的清除,提高终末期肾病(ESRD)患者的认知功能,为改善MHD患者认知功能提供了新途径。

Objective To discuss the effect of enhancing homocysteine clearance by hemodiafiltration(HDF)on cognitive impairment of maintenance hemodialysis(MHD)patients.Methods The cognitive function and homocysteine(HCY)level of MHD patients who meet the criteria for inclusion and exclusion were evaluated,and risk factors related to cognitive function were analyzed.Among the 70 patients who met the criteria for inclusion and exclusion,25 patients dropped out,and the remaining 45 cases were divided into the control group(23 cases)and the treatment group(22 cases)according to the random numerical table.The control group was treated with low-flow hemodialysis(HD),and the treatment group was treated with HDF and low-flow HD.The cognitive function,HCY level and other laboratory indexes were observed before treatment,after 6 months and 12 months of treatment.The effect of increased HCY clearance on cognitive function was observed.Results Cognitive function is negatively correlated with age(r=-0.371,P=0.002<0.05)and HCY level(r=-0.612,P=0.000<0.05),and positively correlated with education level(Spearman rank correlation coefficientρ=0.620,P<0.05)HCY was the only regulator.There was no statistically significant differencein gender,education level,primary disease,age,dialysis age,and dialysis frequency between the two groups(P>0.05).Before treatment,there was no statistically significant difference in laboratory indicators between the two groups(P>0.05).After 6 months of treatment,the cognitive function score(21.64±4.25)points of the treatment group was higher than(18.09±4.67)points of the control group,and the levels of HCY(17.36±5.74)μmol/L,β2 microglobulin(12.02±4.36)mg/L and cystatin C(3.72±0.66)mg/L were lower than(23.96±5.08)μmol/L,(15.51±5.51)mg/L and(5.03±1.03)mg/L of the control group,and the difference was statistically significant(P<0.05).After 12 months of treatment,the cognitive function score(26.27±1.96)points of the treatment group was higher than(17.00±4.73)points of the control group,and the levels of HCY(11.28±3.48)μmol/L,β2 microglobulin(7.99±2.66)mg/L and cystatin C(3.28±0.56)mg/L were lower than(24.40±6.49)μmol/L,(16.14±4.89)mg/L and(4.99±1.21)mg/L of the control group,and the difference was statistically significant(P<0.05).After 12 months of treatment,the phosphate(1.82±0.18)mmol/L,serum creatinine(793.82±141.23)μmol/L,serum uric acid(411.18±74.92)μmol/L,parathyroid hormone(362.19±91.55)ng/L and diastolic blood pressure(79.99±9.37)mm Hg(1 mm Hg=0.133 kPa)in the treatment group were lower than(2.34±0.29)mmol/L,(938.95±205.38)μmol/L,(450.30±53.04)μmol/L,(459.61±131.95)ng/L,(87.39±14.51)mm Hg in the control group,and the difference was statistically significant(P<0.05).After 6 months of treatment,the HCY,β2 microglobulin and cystatin C of the treatment group were lower than those before treatment,and the difference was statistically significant(P<0.05).After 12 months of treatment,the cognitive function score of the treatment group was higher than that before treatment in this group,and the levels of HCY,phosphate,serum creatinine,β2 microglobulin,cystatin C,diastolic blood pressure,and parathyroid hormone were lower than those before treatment in this group.All the difference was statistically significant(P<0.05).In the control group,there was no statistically significant difference in the laboratory indicators before and after treatment(P>0.05).Conclusions HDF can enhance HCY clearance and improve the cognitive function in patients with end-stage renal disease(ESRD),which provides a new way to improve the cognitive function of MHD patients.