持续质量改进对维持性血液透析患者蛋白质-能量消耗的影响

Effect of continuous quality improvement on protein energy wasting in maintenance dialysis patients

目的通过持续质量改进(continuous quality improvement,CQI)的管理方法来干预维持性血液透析患者的蛋白质-能量消耗并探讨其影响。方法选取2016年7月至2017年6月在江阴市人民医院血液净化中心行常规血液透析的85例存在蛋白质-能量消耗(protein-energy wasting,PEW)的患者,建立持续质量改进团队及应用持续质量改进方案,管理对象包括患者及其家属,先后在治疗过程中实施“PDCA”[计划(plan)、实施(do)、检验(check)、应用(act)]步骤,观察期为12个月,比较持续质量改进前后的血清白蛋白(serum albumin,Alb)、血清前白蛋白(pre-albumin,PA)、转铁蛋白(transferrin,TF)、血清胆固醇(serum cholesterol,Tch)、血红蛋白(hemoglobin,Hb)、血肌酐(serum creatinine,Scr)、尿素氮(urea nitrogen,BUN)、血清超敏C反应蛋白(serum hypersensitive c-reactive protein Hs-CRP)、体重指数(body mass index,BMI)、中臂围(midarm circumference,MAC)、中臂肌围(mid-arm circumference,MAMC)、标准化蛋白代谢率(normalized protein catabolic rate,nPCR)、血钙、血磷、全段甲状旁腺素水平(intact parathyroid hormone,iPTH)、改良主观综合营养评估(modified quantitative and global assessment,MQSGA)。观察持续质量改进对这些指标的影响。结果在持续质量改进后,Alb(g/L)、PA(mg/L)、TF(mg/L)、Tch(mmol/L)、Hb(g/L)、BMI(kg/m^(2))水平均较前上升,分别为34.34±3.97比37.26±3.33、252.9±41.7比295.1±39.0、1.52±0.24比1.99±0.25、2.93±0.84比4.23±0.97、83.88±16.75比94.12±13.46、27.58±6.84比28.16±5.78,且均P<0.05,差异有统计学意义。Scr、BUN水平在CQI前后改变不大(t=0.161,P=0.873、t=0.549,P=0.588)。Hs-CRP水平由(20.85±2.09)mg/L下降至(13.15±1.74)mg/L(t=5.02,P<0.01)。在营养指标评估方面,MAC由(22.02±1.63)mm上升至(24.81±1.26)mm(t=5.02,P<0.01),MAMC由(20.68±1.47)mm上升至(22.74±1.40)mm(t=2.603,P=0.017),nPCR由(0.85±0.92)g·kg^(-1)·d^(-1)上升至(1.21±0.21)g·kg^(-1)·d^(-1)(t=1.154,P=0.022),MQSGA轻度比例由77.65%升至88.23%(χ^(2)=4.61,P=0.002),中度比例由18.82%降至10.59%(χ^(2)=3.69,P=0.017),重度比例由3.50%降至1.33%(χ^(2)=5.05,P<0.001)。血钙水平前后波动较小(t=0.629,P=0.537),达标比例由52.0%上升至66.7%(χ^(2)=2.36,P<0.05);血磷平均水平由(2.11±0.24)mmol/L降至(1.80±0.23)mmol/L(t=-0.459,P<0.001),达标比例由19.04%上升至47.62%(χ^(2)=5.13,P<0.001);iPTH水平由(40.79±18.67)pmol/L下降至(24.41±9.82)pmol/L(t=-5.566,P<0.001),达标比例由47.62%上升至71.43%(χ^(2)=4.69,P<0.001)。结论CQI能够显著改善患者的综合营养状况,同时患者的血钙、血磷及iPTH达标比例都得到明显的提升,且没有出现钙磷代谢紊乱,继发性甲状旁腺功能紊乱等状况。

Objective To explore the effect of continuous quality improvement(CQI)on protein energy wasting(PEW)in maintenance hemodialysis patients.Methods From July 2016 to June 2017,85 PEW patients undergoing routine hemodialysis at blood purification center were selected.Through the establishment of CQI team and the application of CQI program,the management objects included patients,their families and implementing"PDCA"(plan,do,check&act)during treatment.The observation period lasted 12 months.Serum albumin(Alb),serum prealbumin(PA),transferrin(TF)and serum cholesterol(serum)before and after CQI were compared cholesterol Tch,hemoglobin(Hb),serum creatinine(Scr),urea nitrogen(BUN),serum hypersensitive C-reactive protein(hs CRP),body mass index(BMI),normalized protein catabolic rate(nPCR),mid arm circumference(MAC)and mid arm circumference(MAMC)were measured.Serum calcium,phosphorus,parathyroid hormone(iPTH)and modified quantitative and global assessment(MQSGA)were recorded.And the impact of CQI on these indicators was observed.Results After CQI,the average levels of Alb(g/L),PA(mg/L),TF(mg/L),Tch(mmol/L),Hb(g/L)and BMI(kg/m^(2))were markedly higher than before(34.34±3.97 vs 37.26±3.33,252.9±41.7 vs 295.1±39.0,1.52±0.24 vs 1.99±0.25,2.93±0.84 vs 4.23±0.97,83.88±16.75 vs 94.12±13.46,27.58±6.84 vs 28.16±5.78,P<0.05).The average level of hs CRP decreased from(20.85±2.09)to(13.15±1.74)mg/L(t=5.02,P<0.01),MAC increased from(22.02±1.63)to(24.81±1.26)mm(t=5.02,P<0.01)and MAMC rose from(20.68±1.47)to(22.74±1.40)mm(t=2.603,P=0.017),nPCR increased from(0.85±0.92)g·kg^(-1)·d^(-1) to(1.21±0.21)g·kg^(-1)·d^(-1)(t=1.154,P=0.022),mild proportion increased from 77.65%to 88.23%(χ^(2)=4.61,P=0.002),moderate proportion declined from 18.82%to 10.59%(χ^(2)=3.69,P=0.017)and severe proportion dropped from 3.5%to 1.33%(χ^(2)=5.05,P<0.001).The average level of serum calcium showed little change(t=0.629,P=0.537),proportion of attaining the standard spiked from 52%to 66.7%(χ^(2)=2.36,P<0.05);average level of blood phosphorus decreased from(2.11±0.24)to(1.80±0.23)mmol/L(t=-0.459,P<0.05),average level of iPTH declined from(40.79±18.67)to(24.41±9.82)pmol/L(t=-5.566,P<0.001)and proportion of reaching the standard jumped from 47.62%to 71.43%(χ^(2)=4.69,P<0.001).Conclusion CQI can significantly improve the comprehensive nutritional status of patients and the proportion of patients with blood calcium,blood phosphorus and iPTH compliance has significantly improved.There is no occurrence of calcium and phosphorus metabolism disorder or secondary parathyroid dysfunction.