糖尿病对维持性血液透析患者生存率的影响及其危险因素分析的回顾性队列研究

Influence of diabetes on survival rate of maintenance hemodialysis patients and analysis of risk factors:a retrospective cohort study

目的探讨糖尿病作为原发病和伴发病对维持性血液透析患者预后的影响并分析全因死亡的危险因素。方法选取2010年1月1日至2016年12月31日于大连市中心医院接受维持性血液透析的602例患者进行回顾性研究,随访至2021年12月31日。根据疾病状况分为原发性糖尿病肾病(DKD)组(257例),糖尿病作为伴发疾病(DCM)组(61例)及无糖尿病(NDM)组(284例)。按年龄≤60岁(324例)及>60岁(278例)进行亚组分析。采用Kaplan-Meier生存曲线分析3组患者的生存率差异,单因素及多因素Cox回归分析探讨全因死亡的危险因素。结果所有患者随访中位时间62个月,全因死亡共329例。三组患者第2~5年的生存率差异有统计学意义(P<0.05)。生存分析结果显示,NDM组患者生存率高于其他2组,差异有统计学意义(P<0.05),DKD组和DCM组患者生存率差异无统计学意义(P=0.162)。多因素Cox回归结果显示,开始透析时年龄(HR 1.01,95%CI 1.01~1.02,P=0.002)、脑卒中(HR 1.44,95%CI 1.08~1.92,P=0.014)、DKD(HR 1.58,95%CI 1.23~2.04,P<0.001)是维持性血液透析患者全因死亡的独立危险因素,尿素清除指数(Kt/V)是全因死亡的保护因素(HR 0.4895%CI 0.29~0.81,P=0.006)。亚组分析结果显示,年龄≤60岁组,脑卒中(HR 1.72,95%CI 1.11~2.65,P=0.015)及DKD(HR 1.97,95%CI 1.33~2.91,P<0.001)是患者全因死亡的独立危险因素,Kt/V(HR 0.37,95%CI 0.18~0.77,P=0.007)是保护性因素;年龄>60岁组,LDL(HR 1.40,95%CI 1.01~1.94,P=0.041)、DKD(HR 1.36,95%CI 1.00~1.85,P=0.049)是患者全因死亡的独立危险因素。结论糖尿病作为原发病和伴发病患者远期生存率无差异,但与NDM患者相比死亡风险明显增加。

Objective To investigate the effect of diabetes as the primary and concomitant disease on prognosis and the risk factors of all-cause death in maintenance hemodialysis patients.Methods A retrospective study was conducted on 602patients who received maintenance hemodialysis from January 1,2010 to December 31,2016 in Dalian Central Hospital,and were followed up until December 31,2021.According to the status of disease,the patients were divided into primary diabetic kidney disease(DKD)group(n=257),diabetes as comorbidity(DCM)group(n=61)and no diabetes mellitus(NDM)group(n=284).Subgroup analysis was performed in patients aged≤60 years(n=324)and older than 60 years(n=278).K-M analysis was used to compare the survival difference among the 3 groups,and univariate and multivariate Cox regression analysis was used to explore the risk factors of all-cause death.Results The median follow-up time of all patients was 62 months,and 329 patients died of all causes.At the 2nd to 5th year,the survival rate of the 3 groups was statistically different(P<0.05).The results of survival analysis showed that the survival rate of NDM group was higher than that of the other 2 groups(P<0.05),but there was no significant difference between DKD group and DCM group in the survival rate(P=0.162).Multivariate Cox regression showed that the age at the beginning of dialysis(HR 1.01,95%CI 1.01-1.02,P=0.002),stroke(HR 1.44,95%CI 1.08-1.92,P=0.014),DKD(HR 1.58,95%CI 1.23-2.04,P<0.001)were independent risk factors for all-cause death in maintenance hemodialysis patients,and Kt/V was a protective factor for allcause death(HR 0.4895%CI 0.29-0.81,P=0.006).Subgroup analysis showed that in the group of age≤60 years,stroke(HR 1.72,95%CI 1.11-2.65,P=0.015)and DKD(HR 1.97,95%CI 1.33-2.91,P<0.001)were independent risk factors for all-cause death,and Kt/V(HR 0.37,95%CI 0.18-0.77,P=0.007)was a protective factor;in the group of age 60 years,LDL(HR 1.40,95%CI 1.01-1.94,P=0.041)and DKD(HR 1.36,95%CI 1.00-1.85,P=0.049)were independent risk factors for all-cause death in the patients.Conclusion There is no difference in long-term survival rate between patients with diabetes as the primary disease and those with concomitant disease,but the risk of death is significantly increased compared with NDM patients.