维持性血液透析患者感染新型冠状病毒的临床特征及死亡危险因素

Clinical features and risk factors of the mortality in hemodialysis patients infected with SARS-CoV-2

目的总结维持性血液透析(maintenance hemodialysis,MHD)患者感染新型冠状病毒(新冠)的临床特征及分析死亡的危险因素,为早期发现危重症患者并及时采取干预措施提供临床数据。方法该研究为横断面调查研究。研究对象为2022年12月1日至2023年1月31日山西省4家地域代表性三甲医院血液透析中心的MHD患者,通过发放新冠感染情况调查表、查阅医院病历系统和门诊血液透析信息化系统等方式收集患者人口学特征、透析相关指标、实验室检查和新冠感染临床特征等资料。按照新冠感染患者研究期间是否发生全因死亡将其分为存活组和死亡组,比较2组患者基线资料的差异。采用多因素Logistic回归模型分析新冠感染MHD患者死亡的危险因素。结果该研究纳入MHD患者519例,研究期间新冠感染508例(97.88%),存活组474例,死亡组34例。新冠感染MHD患者临床症状表现多样,最常见的首发症状为发热(314例,61.81%),其他首发症状包括咳嗽咳痰(66例,12.99%)、乏力(66例,12.99%)、纳差(20例,3.94%)、呼吸困难(20例,3.94%)、肌肉疼痛(14例,2.76%)及腹泻(8例,1.57%)。与存活组比较,死亡组患者年龄较大(t=5.229,P<0.001),男性比例(χ^(2)=12.319,P<0.001)和糖尿病肾病比例(χ^(2)=49.423,P<0.001)均较高,红细胞(t=-5.060,P<0.001)、淋巴细胞(t=-2.614,P=0.011)、中性粒细胞(t=-5.117,P<0.001)、血清白蛋白(t=-2.940,P=0.012)、血清前白蛋白(t=-3.519,P=0.001)、血磷(t=-3.309,P=0.002)、血肌酐(Z=-3.607,P<0.001)、总三酰甘油(Z=-2.486,P=0.013)、总胆固醇(Z=-3.291,P=0.001)、低密度脂蛋白胆固醇(Z=-3.292,P=0.001)水平均较低。新冠感染患者中,使用非甾体抗炎药退烧194例(38.19%),使用抗生素抗感染154例(30.31%),使用抗病毒药物治疗98例(19.29%),接种新冠疫苗225例(43.29%)。多因素Logistic回归分析结果显示,低红细胞(OR=0.256,95%CI 0.014~0.429)、低淋巴细胞(OR=0.487,95%CI 0.193~0.826)、低血清白蛋白(OR=0.613,95%CI 0.329~0.917)、高年龄(OR=1.227,95%CI 1.066~1.412)及合并糖尿病(OR=1.126,95%CI 1.025~1.235)是新冠感染MHD患者死亡的独立影响因素。结论MHD患者感染新冠的临床表现多样。低红细胞、低淋巴细胞、低血清白蛋白、高年龄及合并糖尿病是MHD患者感染新冠死亡的独立危险因素。加强对MHD患者尤其是老年的管理,及时改善和纠正贫血及营养不良,可能降低新冠感染MHD患者死亡的风险。

Objective To investigate the clinical features of patients with maintenance hemodialysis(MHD)infected with SARS-CoV-2 and analyze the risk factors of death after SARS-CoV-2 infection,and to provide clinical data for early detection of critically ill patients and timely intervention.Methods It was a cross-sectional investigation study.MHD patients in the hemodialysis centers of four tertiary hospitals with geographical representation in Shanxi province from December 1,2022 to January 31,2023 were enrolled,and the demographic data,dialysis-related indicators,laboratory test results and clinical features of SARS-CoV-2 infection were collected by distributing the questionnaires on SARS-CoV-2 infection,and consulting the hospital medical record system and the outpatient hemodialysis information system.SARS-CoV-2-infected patients were divided into survival group and death group according to whether all-cause death occurred and the differences of baseline data between the two groups were compared.Multivariate logistic regression analysis method was used to analyze the risk factors of mortality in MHD patients infected with SARS-CoV-2.Results A total of 519 MHD patients were included in this study,with 508 patients(97.88%)infected with SARS-CoV-2,474 patients in the survival group and 34 patients in the death group.The clinical symptoms of MHD patients infected with SARS-CoV-2 were diverse,and the most common initial symptom was fever(314/508,61.81%).Other initial symptoms included cough and phlegm in 66 patients(12.99%),fatigue in 66 patients(12.99%),poor appetite in 20 patients(3.94%),dyspnea in 20 patients(3.94%),muscle pain in 14 patients(2.76%)and diarrhea in 8 patients(1.57%).Compared with the survival group,the death group had older age(t=5.229,P<0.001),high proportions of males(χ^(2)=12.319,P<0.001)and diabetic nephropathy(χ^(2)=49.423,P<0.001),and lower levels of red blood cells(t=-5.060,P<0.001),lymphocyte(t=-2.614,P=0.011),neutrophil(t=-5.117,P<0.001),serum albumin(t=-2.940,P=0.012),serum prealbumin(t=-3.519,P=0.001),blood phosphorus(t=-3.309,P=0.002),serum creatinine(Z=-3.607,P<0.001),total triglyceride(Z=-2.486,P=0.013),total cholesterol(Z=-3.291,P=0.001)and low-density lipoprotein cholesterol(Z=-3.292,P=0.001).Among 508 SARS-CoV-2-infected patients,194 patients(38.19%)were treated with nonsteroidal anti-inflammatory agents,154 patients(30.31%)were treated with antibiotics,and 98 patients(19.29%)were treated with antiviral drugs.There were 225(43.29%)vaccinated patients against SARS-CoV-2.Multivariate logistic regression analysis showed that low red blood cells(OR=0.256,95%CI 0.014-0.429),low lymphocytes(OR=0.487,95%CI 0.193-0.826),low serum albumin(OR=0.613,95%CI 0.329-0.917),older age(OR=1.227,95%CI 1.066-1.412)and diabetes mellitus(OR=1.126,95%CI 1.025-1.235)were the independent influencing factors of all-cause mortality in MHD patients infected with SARS-CoV-2.Conclusions The clinical manifestations of SARS-CoV-2 infection in MHD patients are varied.Low red blood cells,low lymphocytes,low serum albumin,elder age and diabetes mellitus are the independent risk factors of death after SARS-CoV-2 infection in MHD patients.Strengthening management of MHD patients especially in the elderly,and improving and correcting anemia and malnutrition in time,may reduce the death risk of SARS-CoV-2 infection in MHD patients.