慢性肾脏病管理对糖尿病肾病进展及透析启动的影响

Effect of chronic kidney disease management on the disease progression and dialysis initiation in diabetic kidney disease patients

目的了解慢性肾脏病(chronic kidney disease,CKD)门诊管理对糖尿病肾病(diabetic kidney disease,DKD)患者疾病进展及透析启动的影响,为持续改进CKD多学科门诊管理及DKD管理提供依据。方法纳入2015年6月~2021年6月在江苏大学附属医院CKD管理门诊随诊并进入透析的92例DKD患者(管理组),及同时期从肾脏内科专科门诊进入透析的94例DKD患者(非管理组)。比较2组患者首次透析时生化指标,血管通路,住院等情况以及肾功能进展情况,并分析各种因素对DKD病程进展的影响。结果进入透析时,管理组患者的收缩压、估算肾小球滤过率(eGFR)、全段甲状旁腺激素水平都低于非管理组(t值分别为-3.352、-1.196、-1.995;P值分别为0.001、0.047、0.047),血红蛋白、血清白蛋白高于非管理组(t值分别为2.320、2.102;P值分别为0.021、0.037)。首次血液透析时2组在血管通路、紧急透析及首次诱导透析占比间差异有统计学差异(χ^(2)值分别为19.573、16.396、16.969,均P<0.001)。Kaplan-Meier生存分析显示管理组进入透析的中位病程长于非管理组(t=2.239,P=0.021)。多因素分析的结果显示年龄、糖尿病视网膜病变(diabetic retinopathy,DR)、尿微量白蛋白/肌酐是DKD进展的危险因素(HR分别为1.020、0.554、1.000,95%CI 1.003~1.038、0.405~0.757、1.000~1.000,P分别为0.019、<0.001、<0.001),CKD管理及使用血管紧张素转换酶抑制剂(ACEI)/血管紧张素Ⅱ受体拮抗剂(ARB)治疗可减缓DKD进展。结论慢性肾脏病管理能明显延缓DKD进展,在门诊管理中,注重DR的早期筛查和尿蛋白的管理,早期使用ACEI/ARB类药物,对延缓DKD进展有帮助。

Objective To evaluate the influence of chronic kidney disease(CKD)outpatient management on the disease progression and dialysis initiation in diabetic kidney disease(DKD)patients,so as to provide a basis for continuous improvement of the multidisciplinary management of CKD outpatients and DKD patients.Methods This study enrolled 92 DKD patients with initial hemodialysis from the CKD Outpatient Clinic(management group,group M)and 94 DKD patients with initial hemodialysis from the Nephrology Clinic(non-management group,group NM)in the Affiliated Hospital of Jiangsu University in the period from June 2015 to June 2021.Biochemical indexes,vascular access,hospitalization and renal function changes were compared between the two groups at the first dialysis.The impact of various factors on disease progression was evaluated by Cox regression analysis.Results At dialysis entry,systolic blood pressure,estimated glomerular filtration rate(eGFR),and serum whole parathyroid hormone were significantly lower in group M than in group NM(t=-3.352,-1.196 and-1.995 respectively;P=0.001,0.047 and 0.047 respectively),and hemoglobin,serum creatinine and albumin were significantly higher in group M than in group NM(t=2.320,2.189 and 2.102 respectively;P=0.021,0.030 and 0.037 respectively);vascular access,emergent dialysis and the ratio of first induced dialysis at the first dialysis were significantly different between the two groups(χ^(2)=19.573,16.396 and 16.969 respectively;P<0.001).Kaplan-Meier survival analysis showed that the median disease course entering dialysis was significantly longer in group M than in group NM(t=2.239,P=0.21).Multivariate regression analysis showed that age,diabetic retinopathy,urinary microalbumin/creatinine were the risk factor for DKD progression(HR=1.020,0.554 and 1.000 respectively,95%CI:1.003~1.038,0.405~0.757 and 1.000~1.000 respectively;P=0.019,<0.001 and<0.001 respectively).CKD management and treatment with angiotensin converting enzyme inhibitors(ACEI)/angiotensin II receptor blocker(ARB)could postpone the DKD progression.Conclusion CKD management can significantly delay the progression of DKD.In outpatient management,early screening of diabetic retinopathy,management of urinary protein,and early use of ACEI/ARB medications are helpful to delay the DKD progression.