儿童慢性肾脏病5期病因分析及并发症研究

Analysis of etiology and complications in children with stage 5 chronic kidney disease

目的:了解儿童慢性肾脏病(CKD)5期的病因、并发症及影响疾病预后的因素。方法:病例系列研究,回顾性分析2012年4月至2021年4月于重庆医科大学附属儿童医院确诊CKD 5期并住院治疗的174例患儿的一般情况、临床表现、实验室检查、基因检测及随访情况(截至2022年10月)等临床资料,根据年龄、性别和病因分组比较患儿并发症的特点;根据有无左心室肥厚(LVH)分为LVH组和非LVH组,分析发生心血管疾病的影响因素;根据随访时情况分为死亡组和存活组、腹膜透析组和血液透析组,分析影响预后的相关因素。组间比较采用χ^(2)检验、独立样本t检验、Fisher确切概率法、Mann-Whitney U检验及Kruskal-Wallis检验,采用二元Logistic回归分析与疾病预后相关的因素。结果:174例CKD 5期患儿中男96例、女78例,初诊年龄11.2(8.2,13.0)岁。主要病因为先天性肾脏和尿路畸形(CAKUT)(84例,48.3%)及肾小球疾病(83例,47.7%),其中遗传性肾小球病28例(16.1%)。主要并发症依次为贫血(98.2%,165/168),慢性肾脏病合并骨矿物质代谢异常(CKD-MBD)(97.7%,170/174),脂代谢紊乱(87.5%,63/72),高血压(81.4%,127/156),LVH(57.6%,57/99)。原发性肾小球疾病高血压发生率高于CAKUT[93.8%(30/32)比73.7%(56/76),χ^(2)=5.59,P<0.05],继发性肾小球疾病高血压发生率高于CAKUT和遗传性肾小球病[100.0%(20/20)比73.7%(56/76)、68.2%(15/22),均P<0.05]。CAKUT、原发性肾小球疾病及遗传性肾小球病的低钙血症发生率均高于继发性肾小球疾病[82.1%(69/84)、88.2%(30/34)、89.3%(25/28)比47.6%(10/21),χ^(2)=10.21、10.75、10.80,均P=0.001]。女性继发性甲状旁腺功能亢进发生率高于男性[80.0%(64/80)比95.0%(57/60),χ^(2)=6.58,P=0.010]。6~<12岁患儿LVH发生率高于12~18岁[73.5%(25/34)比43.1%(22/51),χ^(2)=7.62,P=0.006]。113例随访患儿中,病死率为39.8%(45/113),死亡组患儿较存活组血红蛋白低、收缩压高、舒张压高、白蛋白低、碱性磷酸酶低、左心室质量指数高[(67±19)比(75±20)g/L、142(126,154)比128(113,145)mmHg(1 mmHg=0.133 kPa)、(91±21)比(82±22)mmHg、32(26,41)比40(31,43)g/L、151(82,214)比215(129,37)U/L、48(38,66)比38(32,50)g/m^(2).7,t=2.03,Z=2.89,t=2.70,Z=2.49、2.79、2.29,均P<0.05],未发现预后相关独立危险因素(均P>0.05);腹膜透析组患儿贫血、低钙、高磷纠正均优于血液透析组[(87±22)比(72±16)g/L、(1.9±0.5)比(1.7±0.4)mmol/L、(2.2±0.7)比(2.8±0.9)mmol/L,t=2.92、2.29、2.82,均P<0.05],腹膜透析组患儿存活比例明显高于血液透析组[77.8%(28/36)比48.4%(30/62),χ^(2)=8.14,P=0.004]。结论:CKD 5期患儿病因以CAKUT多见;贫血是最常见的并发症;不同年龄、性别及病因CKD 5期患儿并发症发生率存在差异;贫血、高血压、低白蛋白血症、碱性磷酸酶降低与LVMI升高可能是CKD 5期患儿的预后相关因素;腹膜透析可能更有利于患儿长期存活。

Objective To investigate the etiology,complications,and prognostic factors of stage 5 chronic kidney disease(CKD5)in children.Methods A case series study was conducted to retrospectively analyze the general situation,clinical manifestations,laboratory tests,genetic testing,and follow-up data(until October 2022)of 174 children with CKD5 who were diagnosed and hospitalized at the Children′s Hospital of Chongqing Medical University from April 2012 to April 2021.The characteristics of complications in the children were compared based on age,gender,and etiology.Based on the presence or absence of left ventricular hypertrophy(LVH),patients were divided into LVH group and non LVH group for analyzing the influencing factors of cardiovascular disease.Patients were also divided into death group and survival group,peritoneal dialysis group and hemodialysis group based on the follow-up data for analyzing the prognostic factors.The chi-square test,independent sample t-test,Fisher exact probability test,Mann-Whitney U test and Kruskal Wallis test were used to analyze data among different groups.Multivariate Logistic regression analysis was used to identify the prognostic factors.Results A total of 174 children with CKD5 were enrolled in the study(96 boys and 78 girls),aged 11.2(8.2,13.0)years.Congenital kidney and urinary tract malformations(CAKUT)were the most common causes of the CKD5(84 cases,48.3%),followed by glomerular diseases(83 cases,47.7%),and among which 28 cases(16.1%)were hereditary glomerular diseases.The common complications of CKD5 included anemia(98.2%,165/168),mineral and bone disorder in chronic kidney disease(CKD-MBD)(97.7%,170/174),lipid metabolism disorders(87.5%,63/72),hypertension(81.4%,127/156)and LVH(57.6%,57/99).The incidences of hypertension in primary glomerular disease were higher than that in CAKUT(93.8%(30/32)vs.73.7%(56/76),χ^(2)=5.59,P<0.05).The incidences of hypertension in secondary glomerular disease were higher than that in CAKUT and that in hereditary kidney disease(100.0%(20/20)vs.73.7%(56/76),68.2%(15/22),both P<0.05).The incidence of hypocalcemia in CAKUT,primary glomerular disease,and hereditary kidney disease was higher than that in secondary glomerular disease(82.1%(69/84),88.2%(30/34),89.3%(25/28)vs.47.6%(10/21),χ^(2)=10.21,10.75,10.80,all P=0.001);the incidence of secondary hyperparathyroidism in women was higher than that in men(80.0%(64/80)vs.95.0%(57/60),χ^(2)=6.58,P=0.010).The incidence of LVH in children aged 6-<12 was higher than that in children aged 12-18(73.5%(25/34)vs.43.1%(22/51),χ^(2)=7.62,P=0.006).Among 113 follow-up children,the mortality rate was 39.8%(45/113).Compared to the survival group,the children in the death group had lower hemoglobin,higher blood pressure,lower albumin,lower alkaline phosphatase and higher left ventricular mass index((67±19)vs.(75±20)g/L,142(126,154)vs.128(113,145)mmHg(1 mmHg=0.133 kPa),(91±21)vs.(82±22)mmHg,32(26,41)vs.40(31,43)g/L,151(82,214)vs.215(129,37)U/L,48(38,66)vs.38(32,50)g/m^(2).7,t=2.03,Z=2.89,t=2.70,Z=2.49,2.79,2.29,all P<0.05),but no independent risk factors were identified(all P>0.05).The peritoneal dialysis group had better alleviation for anemia,low calcium,and high phosphorus than the hemodialysis group((87±22)vs.(72±16)g/L,(1.9±0.5)vs.(1.7±0.4)mmol/L,(2.2±0.7)vs.(2.8±0.9)mmol/L,t=2.92,2.29,2.82,all P<0.05),and the survival rate of the peritoneal dialysis group was significantly higher than that of the hemodialysis group(77.8%(28/36)vs.48.4%(30/62),χ^(2)=8.14,P=0.004).Conclusions CAKUT is the most common etiology in children with CKD 5,and anemia is the most common complication.The incidence of complications in children with CKD 5 varies with age,gender and etiology.Anemia,hypertension,hypoalbuminemia,reduced alkaline phosphatase and elevated LVMI may be the prognostic factors in children with CKD5.Peritoneal dialysis may be more beneficial for improving the long-term survival rate.