目的:探索高海拔地区维持性血液透析(MHD)间期患者代谢性酸中毒(MA)的发生及不良结局。方法:选取青海大学附属医院肾病内科血透室的MHD患者67例,于透析间期对患者进行动脉血气分析及常规实验室检测。根据患者的碳酸氢根HCO 3 -值将患者分为MA组( HCO 3 -≤ 21 mmol/L)和非MA组( HCO 3 -> 21 mmol/L),收集患者的一般资料和临床资料,比较两组一般资料、临床资料和实验室指标的差异,探讨MA的发生及不良结局。符合正态分布的计量资料用( X ±s)表示,组间比较采用t检验;计量资料为非正态分布的用中位数和四分位数间距表示,组间比较采用秩和检验;危险因素分析采用Logistic回归分析。结果:两组的抽烟比例、饮酒比例、合并心血管疾病比例、不饱和铁结合力UIBC、血钾K、血尿素氮BUN、发生消化道不适比例、发生心律失常比例、红细胞计数RBC、红细胞压积HCT、血红蛋白HB、血清白蛋白ALB的P < 0.05,存在统计学差异,回归分析提示抽烟比例、饮酒比例、合并心血管疾病比例、不饱和铁结合力UIBC的P < 0.05,存在统计学差异。结论:高海拔地区MHD间期发生MA比平原地区更常见,其抽烟、饮酒比例的升高、合并心血管疾病比例的增加、UIBC的降低是发生MA的危险因素,BUN、K的升高加重了MHD间期MA的发生,而MA可能参与了患者营养不良、心律失常及消化道症状的发生,其中MA患者在缺氧环境下一定程度上可能导致了代偿性红细胞增多。 Objective: To explore the incidence and adverse outcomes of metabolic acidosis (MA) in maintenance hemodialysis (MHD) patients at high altitude. Methods: Sixty-seven MHD patients were selected from the hemodialysis room of Department of Nephrology, The Affiliated Hospital of Qinghai University. Patients were divided into MA group ( HCO 3 -≤ 21 mmol/L) and non-MA group ( HCO 3 -> 21 mmol/L) according to their bicarbonate HCO 3 - values. The general data and clinical data of patients were collected, and the differences of general data, clinical data and laboratory indexes between the two groups were compared to discuss the occurrence and adverse outcomes of MA. The measurement data conforming to normal distribution is expressed by ( X±s), and the comparison between groups adopts t test. The data with non-normal distribution are expressed by median and interquartile distance, and rank sum test is used for comparison between groups. Risk factors were analyzed by Logistic regression analysis. Results: P values of the smoking ratio, drinking ratio, combined cardiovascular disease ratio, unsaturated iron binding capacity UIBC, blood potassium K, blood urea nitrogen BUN, digestive tract discomfort ratio, arrhythmia ratio, red cell count RBC, hematocrit HCT, hemoglobin HB, serum albumin ALB of the two groups were <0.05, and there were statistical differences. Regression analysis showed that there were statistical differences in the proportion of smoking, drinking, cardiovascular diseases and unsaturated iron binding force UIBC (P < 0.05). Conclusion: The occurrence of MA during MHD interval in high altitude areas is more common than that in plain areas. The increase of smoking and drinking, the increase of cardiovascular diseases and the decrease of UIBC are the risk factors of MA. The increase of BUN and K aggravates the occurrence of MA during MHD interval, and MA may be involved in the occurrence of malnutrition, arrhythmia and digestive tract symptoms, among which MA patients under the hypoxia environment may lead to compensatory polycythemia to a certain extent.
目的:探索高海拔地区维持性血液透析(MHD)间期患者代谢性酸中毒(MA)的发生及不良结局。方法:选取青海大学附属医院肾病内科血透室的MHD患者67例,于透析间期对患者进行动脉血气分析及常规实验室检测。根据患者的碳酸氢根HCO3-值将患者分为MA组( H C O 3 − ≤ 21 mmol/L)和非MA组( H C O 3 − > 21 mmol/L),收集患者的一般资料和临床资料,比较两组一般资料、临床资料和实验室指标的差异,探讨MA的发生及不良结局。符合正态分布的计量资料用( x ¯ ± s )表示,组间比较采用t检验;计量资料为非正态分布的用中位数和四分位数间距表示,组间比较采用秩和检验;危险因素分析采用Logistic回归分析。结果:两组的抽烟比例、饮酒比例、合并心血管疾病比例、不饱和铁结合力UIBC、血钾K、血尿素氮BUN、发生消化道不适比例、发生心律失常比例、红细胞计数RBC、红细胞压积HCT、血红蛋白HB、血清白蛋白ALB的P < 0.05,存在统计学差异,回归分析提示抽烟比例、饮酒比例、合并心血管疾病比例、不饱和铁结合力UIBC的P < 0.05,存在统计学差异。结论:高海拔地区MHD间期发生MA比平原地区更常见,其抽烟、饮酒比例的升高、合并心血管疾病比例的增加、UIBC的降低是发生MA的危险因素,BUN、K的升高加重了MHD间期MA的发生,而MA可能参与了患者营养不良、心律失常及消化道症状的发生,其中MA患者在缺氧环境下一定程度上可能导致了代偿性红细胞增多。
高海拔,维持性血液透析,代谢性酸中毒,相关因素,营养状态,心律失常
Haihong Ran1, Wei Li2*
1Qinghai University, Xining Qinghai
2Department of Critical Care Medicine, Center Hospital of Hefeng County, Hefeng County Hubei
Received: Dec. 18th, 2021; accepted: Jan. 7th, 2022; published: Jan. 24th, 2022
Objective: To explore the incidence and adverse outcomes of metabolic acidosis (MA) in maintenance hemodialysis (MHD) patients at high altitude. Methods: Sixty-seven MHD patients were selected from the hemodialysis room of Department of Nephrology, The Affiliated Hospital of Qinghai University. Patients were divided into MA group ( H C O 3 − ≤ 21 mmol/L) and non-MA group ( H C O 3 − > 21 mmol/L) according to their bicarbonate H C O 3 − values. The general data and clinical data of patients were collected, and the differences of general data, clinical data and laboratory indexes between the two groups were compared to discuss the occurrence and adverse outcomes of MA. The measurement data conforming to normal distribution is expressed by ( x ¯ ± s ), and the comparison between groups adopts t test. The data with non-normal distribution are expressed by median and interquartile distance, and rank sum test is used for comparison between groups. Risk factors were analyzed by Logistic regression analysis. Results: P values of the smoking ratio, drinking ratio, combined cardiovascular disease ratio, unsaturated iron binding capacity UIBC, blood potassium K, blood urea nitrogen BUN, digestive tract discomfort ratio, arrhythmia ratio, red cell count RBC, hematocrit HCT, hemoglobin HB, serum albumin ALB of the two groups were <0.05, and there were statistical differences. Regression analysis showed that there were statistical differences in the proportion of smoking, drinking, cardiovascular diseases and unsaturated iron binding force UIBC (P < 0.05). Conclusion: The occurrence of MA during MHD interval in high altitude areas is more common than that in plain areas. The increase of smoking and drinking, the increase of cardiovascular diseases and the decrease of UIBC are the risk factors of MA. The increase of BUN and K aggravates the occurrence of MA during MHD interval, and MA may be involved in the occurrence of malnutrition, arrhythmia and digestive tract symptoms, among which MA patients under the hypoxia environment may lead to compensatory polycythemia to a certain extent.
Keywords:High Altitude, Maintenance Hemodialysis, Metabolic Acidosis, Correlative Factor, Nutritional Status, Arrhythmia
Copyright © 2022 by author(s) and Hans Publishers Inc.
This work is licensed under the Creative Commons Attribution International License (CC BY 4.0).
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慢性肾脏病CKD是指各种因素引起的肾脏结构和功能损伤超过3个月,包括肾小球滤过率eGFR的改变相关的病理损伤、实验室检测异常及影像学检查异常,或不明原因导致的eGFR < 60 mL/min大于3个月。临床上CKD的病程常呈不可逆性的慢性进展,最终导致终末期肾病ESRD [
选取2020年11月至2021年08月青海大学附属医院肾内科血液透析室明确诊断为慢性肾脏病(CKD-5期)并进行维持性血液透析(MHD)治疗的患者67例。均取得患者知情同意。排除同时患有严重肝衰竭、肿瘤、肺心病、急、慢性感染及睡眠呼吸暂停低通气综合征者,同期行手术患者以及血液透析合并腹膜透析者。所有患者均采用符合国际标准的先进透析仪,透析液制备均符合ISO标准(碳酸氢盐透析液),血流量为200 ml/min,透析液流量为500 ml/min。
将选取的67例维持性血液透析MHD的患者分为两组,代谢性酸中毒MA组( HCO 3 − ≤ 21 mmol/L)和非代谢性酸中毒MA组( HCO 3 − > 21 mmol/L)。
于抽血当日收集患者的性别、年龄(岁)、文化程度、抽烟、饮酒、高钾饮食、睡眠时间(h)。
于抽血当日收集原发病、病程(年)、透析龄(月)、透析后体重(kg)、血压(mmHg)、服药情况、发生并发症情况。
于抽血第二日收集血常规(白细胞计数WBC、红细胞计数RBC、血红蛋白HGB、红细胞压积HCT、血小板计数PLT等),生化(白蛋白ALB、碱性磷酸酶ALP、丙氨酸氨基转移酶ALT、天冬氨酸氨基转移酶AST、谷氨酰基转移酶GGT、总胆红素TBIL、直接胆红素DBIL、间接胆红素IBIL、尿素氮BUN、肌酐SCr、尿酸UA、钙Ca、磷P、镁Mg、氯CL、钾K、钠Na、不饱和铁结合力UIBC、血清铁SI等),余包括铁蛋白SF、C反应蛋白CRP、血沉ESCR、甲状旁腺激素iPTH、同型半胱氨酸HCY,计算转铁蛋白饱和度TSAT (TSAT计算公式为:血清铁/TIBC × 100%)、肾小球滤过率eGFR (MDRD简化公式:男性eGFR = 175 × Cr-1.234 × 年龄 − 0.179;女性eGFR = 175 × Cr-1.234 × 年龄 − 0.179 × 0.79)、钙磷乘积Ca × P (公式校正血[Ca2+] (mg/L) = 实测[Ca2+] (mg/L) + 0.8 × (4-白蛋白值)计算血清校正钙值)、Kt/V (Kt/V = −ln(R-0.008 × t) + (4 − 3.5 × R) × UF/W,W为透析后体重,UF为超滤量,t为透析时间,R为透析后与透析前的血尿素比值。
利用SPSS23.0软件,计量资料符合正态分布用( x ¯ ± s )表示,两组间比较采用t检验;非正态分布的计量资料用中位数和四分位数间距表示,组间比较采用秩和检验;危险因素分析采用Logistic回归分析。按检验水准P < 0.05表示差异具有统计学意义。
在67例病例中,男性50例,女性17例,平均年龄(55.01 ± 11.87)岁;平均透析龄(31.07 ± 26.72)月;分为两组后,两组间患者的性别、年龄、文化程度、高钾饮食、睡眠时间无差异,抽烟、饮酒比例的P < 0.05,具有统计学意义。见表1。
项目 | MA组(n = 34) | 非MA组(n = 33) | X2/F | P |
---|---|---|---|---|
性别(%) | 0.835 | >0.05 | ||
男 | 27 (79.4) | 23 (69.7) | ||
女 | 7 (20.6) | 10 (30.3) | ||
文化程度(%) | >0.05 | |||
本科 | 2 (5.9) | 2 (6.0) | 0.001 | |
大专 | 2 (5.9) | 2 (6.0) | 0.001 | |
高中 | 4 (11.8) | 1 (3.0) | 1.850 | |
中专 | 4 (11.8) | 1 (3.0) | 1.850 | |
初中 | 5 (14.7) | 8 (24.2) | 0.974 | |
小学及以下 | 17 (50.0) | 19 (57.6) | 0.387 | |
抽烟(%) | 19 (55.9) | 5 (15.2) | 12.085 | <0.05 |
饮酒(%) | 15 (44.1) | 3 (9.0) | 10.457 | <0.05 |
高钾饮食(%) | 22 (64.7) | 21 (63.6) | 0.008 | >0.05 |
年龄(岁) | 55.50 ± 10.96 | 54.52 ± 12.89 | 1.770 | >0.05 |
睡眠时间(h) | 4.76 ± 1.76 | 5.27 ± 1.42 | 2.067 | >0.05 |
表1. 两组一般资料的比较[(n%) ( x ¯ ± s )]
*注:P < 0.05,具有统计学意义。
67例病例中,原发病中慢性肾小球肾炎31例,占46.3%,糖尿病肾病20例,占29.9%,其他包括高血压肾病6例,多囊肾3例,痛风性肾病2例,慢性间质性肾炎1例,狼疮性肾炎1例,紫癜性肾炎1例,肾病综合征1例,梗阻性肾病1例。两组患者的慢性肾小球肾炎、糖尿病肾病、服用司维拉姆、服用骨化三醇、发生低血压比例及病程、透析龄、平均动脉压无差异,发生心律失常、发生消化道不适、合并心血管疾病比例的P < 0.05,具有统计学意义。见表2。
项目 | MA组(n = 34) | 非MA组(n = 33) | X2/Z/F | P |
---|---|---|---|---|
慢性肾小球肾炎(%) | 15 (44.1) | 16 (48.4) | 0.128 | >0.05 |
糖尿病肾病(%) | 13 (38.2) | 7 (21.2) | 2.318 | >0.05 |
服用司维拉姆(%) | 24 (70.6) | 21 (63.6) | 0.367 | >0.05 |
服用骨化三醇(%) | 20 (58.9) | 19 (57.6) | 0.011 | >0.05 |
发生低血压(%) | 9 (26.5) | 12 (36.4) | 0.762 | >0.05 |
发生心律失常(%) | 21 (61.8) | 11 (33.3) | 5.426 | <0.05 |
发生消化道不适(%) | 21 (61.8) | 9 (27.3) | 8.057 | <0.05 |
病程(年) | 6.50 (4.00, 10.25) | 7.00 (5.00, 11.00) | −0.396 | >0.05 |
透析龄(月) | 24.00 (12.00, 39.00) | 24.00 (12.00, 42.00) | −0.609 | >0.05 |
平均动脉压(mmHg) | 101.65 ± 13.08 | 100.70 ± 14.78 | 0.045 | >0.05 |
合并心血管疾病(%) | 28 (82.4) | 17 (51.5) | 7.221 | <0.05 |
表2. 两组临床资料的比较[(n%), x ¯ ± s , M(P25, P75)]
*注:P < 0.05,具有统计学意义。
两组患者的白细胞计数RBC、血小板计数PLT、尿酸UA、血肌酐SCr、肾小球滤过率eGFR、胆固醇TC、甘油三酯TG、高密度脂蛋白HDL、低密度脂蛋白LDL、钙磷乘积Ca × P、镁Mg、氯Cl、转铁蛋白饱和度TSAT、碱性磷酸酶ALP、丙氨酸氨基转移酶ALT、天冬氨酸氨基转移酶AST、谷氨酰基转移酶GGT、总胆红素TBIL、直接胆红素DBIL、间接胆红素IBIL、铁蛋白SF、血清铁SI、C反应蛋白CRP、血沉ESCR、甲状旁腺激素iPTH、同型半胱氨酸HCY值无差异,红细胞计数RBC、红细胞压积HCT、血红蛋白HB、血钾K、血尿素氮BUN水平、血清白蛋白ALB、不饱和铁结合力UIBC的P < 0.05,具有统计学意义。见表3。
低 HCO 3 − 组(n = 34) | 高 HCO 3 − 组(n = 33) | F/Z | P | |
---|---|---|---|---|
WBC (×109/L) | 6.04 ± 2.03 | 6.26 ± 1.80 | 0.179 | >0.05 |
RBC (×1012/L) | 3.85 ± 0.48 | 3.52 ± 0.78 | 7.255 | <0.05 |
HCT (%) | 35.30 ± 4.61 | 32.52 ± 6.16 | 3.559 | <0.05 |
HB (g/L) | 113.95 ± 15.37 | 104.64 ± 19.98 | 3.811 | <0.05 |
PLT (×109/L) | 164.44 ± 64.52 | 178.00 ± 45.23 | 2.935 | >0.05 |
ALB (g/L) | 37.96 ± 4.31 | 41.61 ± 3.08 | 7.829 | <0.05 |
UA (umol/L) | 386.79 ± 84.36 | 375.24 ± 105.13 | 0.194 | >0.05 |
BUN (mmol/L) | 28.17 ± 7.61 | 23.98 ± 7.07 | 0.00 | <0.05 |
SCr (umol/L) | 850.91 ± 248.10 | 850.79 ± 231.91 | 0.486 | >0.05 |
eGFR (ml/min) | 6.32 ± 3.02 | 6.16 ± 2.38 | 1.646 | >0.05 |
TC (mmol/L) | 3.51 ± 0.73 | 3.76 ± 0.91 | 1.749 | >0.05 |
HDL (mmol/L) | 0.98 ± 0.24 | 1.08 ± 0.30 | 1.775 | >0.05 |
LDL (mmol/L) | 1.85 ± 0.63 | 2.05 ± 0.73 | 0.721 | >0.05 |
P (mmol/L) | 1.77 ± 0.47 | 1.79 ± 0.49 | 0.049 | >0.05 |
Ca×P (mmol/L) | 4.01 ± 1.12 | 4.04 ± 1.12 | 0.004 | >0.05 |
Mg (mmol/L) | 1.13 ± 0.16 | 1.07 ± 0.12 | 2.154 | >0.05 |
CL (mmol/L) | 100.20 ± 4.18 | 100.47 ± 3.31 | 3.038 | >0.05 |
K (mmol/L) | 5.01 ± 0.60 | 4.67 ± 0.67 | 0.373 | <0.05 |
UIBC (umol/L) | 34.33 ± 8.29 | 38.92 ± 9.56 | 1.082 | <0.05 |
TSAT (%) | 25.77 ± 9.13 | 22.92 ± 9.70 | 0.014 | >0.05 |
TG (mmol/L) | 1.31 (1.05,1.76) | 1.43 (1.07, 1.94) | −0.577 | >0.05 |
Ca (mmol/L) | 2.20 (2.16,2.30) | 2.23 (2.11, 2.42) | −0.452 | >0.05 |
ALP (U/A) | 111.00 (79.75, 146.00) | 127.00 (93.50, 175.00) | −1.129 | >0.05 |
ALT (U/L) | 12.50 (8.75, 20.00) | 14.00 (9.00, 22.00) | −0.490 | >0.05 |
AST (U/L) | 13.00 (9.75, 17.00) | 14.00 (11.50, 20.00) | −1.187 | >0.05 |
GGT (U/L) | 21.50 (15.00, 38.50) | 24.00 (14.00, 58.50) | −0.882 | >0.05 |
TBIL (umol/L) | 6.75 (5.00, 9.78) | 8.30 (6.30, 10.35) | −1.054 | >0.05 |
DBIL (umol/L) | 2.60 (1.88, 3.73) | 3.10 (2.20, 4.10) | −1.130 | >0.05 |
IBIL (umol/L) | 4.10 (3.08, 7.03) | 5.00 (3.70, 6.10) | −0.709 | >0.05 |
SF (ng/mL) | 75.18 (40.43, 156.26) | 61.47 (28.78, 157.75) | −0.909 | >0.05 |
SI (umol/L) | 10.40 (8.14, 15.59) | 10.40 (7.98, 12.99) | −0.690 | >0.05 |
CRP (ng/L) | 4.24 (3.12, 11.20) | 3.12 (3.12, 7.67) | −1.243 | >0.05 |
ESCR (mm/h) | 30.50 (18.50, 51.00) | 27.00 (12.50, 46.00) | −1.098 | >0.05 |
iPTH (pg/mL) | 367.00 (251.45, 503.45) | 392.00 (248.95, 730.70) | −0.546 | >0.05 |
HCY (umol/L) | 30.35 (22.81, 47.76) | 27.05 (20.81, 44.51) | −0.223 | >0.05 |
表3. 两组实验室指标的比较[ x ¯ ± s , M(P25, P75)]
*注:P < 0.05,具有统计学意义。
结果提示,抽烟、饮酒、合并心血管疾病比例、不饱和铁结合力UIBC的P < 0.05,具有统计学意义。见表4。
指标 | 回归系数 | OR值 | 95% CI | P值 |
---|---|---|---|---|
抽烟 | 1.959 | 7.093 | 2.206~22.805 | <0.05 |
饮酒 | 2.066 | 7.895 | 2.014~30.954 | <0.05 |
合并心血管疾病 | 1.480 | 4.392 | 1.440~13.396 | <0.05 |
UIBC | 0.59 | 1.061 | 1.001~1.124 | <0.05 |
表4. MA的危险因素
*注:P < 0.05,具有统计学意义。
慢性肾脏病CKD目前的国际指南将其定义为无论何种潜在原因导致的肾功能下降,表现为肾小球滤过率降低或和肾脏损伤,持续时间 ≥ 3个月 [
相关研究表明,香烟中含有镉,肾脏对镉极为敏感,镉主要通过氧化应激、细胞死亡和炎症机制对肾脏血管及细胞造成损伤 [
本研究结果(见表3)提示,MA组的患者HB、红细胞计数HB、红细胞压积HCT更高,该结果与平原地区文献报道存在差异,推论是由于透析间期MA的发生率高,同时缺乏吸氧设备,缺氧加重导致的代偿性的红细胞增多。患者发生代谢性酸中毒MA时存在深大呼吸,进一步加重缺氧,导致代偿性红细胞增多的发生,国外一项研究表明,在生活在相对高海拔的人群,终末期肾病ESRD患者的血红蛋白HGB水平较高 [
综上所述,通过对维持性血液透析MHD患者代谢性酸中毒MA的相关研究得出,高海拔地区MA的发生率相对较高,抽烟、饮酒、合并心血管疾病比例的升高,不饱和铁结合力UIBC的降低是发生MA的危险因素,由于民族、饮食习俗的差异使得其更易发生MA;研究结果还提示,血尿素氮BUN、血钾K的升高可能参与了MA的进程,代偿性红细胞增多、发生心律失常、消化道症状、营养不良可能是MA导致的不良结局,其中高海拔地区存在的缺氧环境,加速了MA的进展,使得部分结果与平原地区报道有所差异,由于本研究样本量较少,还需进一步加大样本量对MA发生的危险因素和不良结局做研究,共同探讨改善MHD患者预后的措施。
冉海鸿,李 伟. 高海拔地区维持性血液透析间期患者代谢性酸中毒的发生及不良结局Incidence and Adverse Outcome of Metabolic Acidosis in Maintenance Hemodialysis Patients at High Altitude[J]. 临床医学进展, 2022, 12(01): 343-351. https://doi.org/10.12677/ACM.2022.121052