本文選題：慢性腎臟病 + 代謝性酸中毒�。� 參考：《大連醫(yī)科大學》2017年碩士論文

【摘要】：目的:代謝性酸中毒是慢性腎臟病常見并發(fā)癥,代謝性酸中毒對人體可產(chǎn)生多種危害。本研究旨在研究慢性腎臟病代謝性酸中毒的發(fā)生情況以及分析相關(guān)影響因素。方法:選取大連醫(yī)科大學附屬第二醫(yī)院腎內(nèi)科2016年1月-2016年9月新入院患者301例,遼寧腎人民醫(yī)院腎內(nèi)科2016年4月-2016年12月新入院患者567例。入選標準:確診為慢性腎臟病。排除標準:1.年齡18歲。2.急性腎功能衰竭。3.行甲狀旁腺素切除。4.明確診斷存在甲狀腺功能異常。5.存在乳酸酸中毒或酮癥酸中毒。6.存在原發(fā)性腎小管酸中毒。慢性腎臟病的定義和分期參考美國腎臟病基金會制定的KDOQI指南。估算腎小球濾過率(eGFR),應用CKD-EPF(2007)計算公式。本研究分析了同時具有血氣分析碳酸氫根離子濃度和靜脈血二氧化碳結(jié)合力資料190例,經(jīng)線性相關(guān)分析結(jié)果顯示碳酸氫鹽濃度與二氧化碳結(jié)合力有很好的正相關(guān)性,二氧化碳結(jié)合力可以作為代謝性酸中毒的評估指標。因此,本研究將二氧化碳結(jié)合力22 mmol/L定義為代謝性酸中毒。依據(jù)二氧化碳結(jié)合力水平CO2-CP 22-30 mmol/L和CO2-CP22 mmol/L分為非代謝性酸中毒和代謝性酸中毒組。記錄患者一般信息:性別、年齡、身高、體重、BMI、收縮壓、舒張壓、原發(fā)病的類型,是否合并高血壓、糖尿病,是否服用鈣離子拮抗劑、β受體阻滯劑、ACEI/ARB類藥物,是否行腎臟替代療法及腎臟替代療法的類型。所有血液標本均為入院當天采集,血液透析患者為透析前采血,心電圖檢查為入院當天完成。化驗檢查指標:血肌酐、二氧化碳結(jié)合力、HCO3-濃度、血紅蛋白、C反應蛋白、三碘甲狀原氨酸(T3)、甲狀腺素(T4)、促甲狀腺素(TSH)、甲狀旁腺素、總蛋白、白蛋白、球蛋白、白球比、尿素氮、胱抑素C、血尿酸、甘油三酯、總膽固醇、高密度脂蛋白、低密度脂蛋白、脂蛋白a、血鉀、血鈉、血氯、血鈣、血磷、血鎂。心電圖檢查:QT間期,QTc間期。所有數(shù)據(jù)經(jīng)SPSS23.0統(tǒng)計軟件進行分析。結(jié)果:1.一般資料:本研究一共入選868例患者,其中男性447例,女性421例,年齡(19~93)歲,平均年齡63.16±14.29歲。ckd1期47例,ckd2期64例,ckd3期83例,ckd4期88例,ckd5期非透析310例,血液透析患者84例,腹膜透析患者192例。原發(fā)病分類:原發(fā)性腎小球腎炎541例,2型糖尿病192例,高血壓59例,間質(zhì)性腎炎30例,多囊腎23例,痛風5例,系統(tǒng)紅斑狼瘡4例,泌尿系感染2例,anca相關(guān)性血管炎2例,腎囊腫2例,過敏性紫癜2例,其他一共6例。2.分析190例患者靜脈血二氧化碳結(jié)合力與動脈血碳酸氫根離子濃度關(guān)系發(fā)現(xiàn):二氧化碳結(jié)合力均值18.65±5.20mmol/l,碳酸氫根濃度均值19.35±5.31mmol/l,經(jīng)獨立樣本t檢驗,差異無統(tǒng)計學意義(p0.05);兩組計量資料經(jīng)過直線關(guān)系分析,皮爾遜相關(guān)系數(shù)r=0.933(p0.001),提示二氧化碳結(jié)合力與碳酸氫鹽濃度呈線性正相關(guān),二氧化碳結(jié)合力可以作為衡量代謝性酸中的指標,因此本研究將二氧化碳結(jié)合力22mmol/l定義為代謝性酸中毒。3.本研究依據(jù)ckd分期分為ckd1-5組、血液透析組、腹膜透析組。7組之間二氧化碳結(jié)合力均值差異有統(tǒng)計學意義(p0.05)。經(jīng)兩兩比較ckd1期患者二氧化碳結(jié)合力均值高于ckd4期、ckd5期及血液透析患者二氧化碳結(jié)合均值,差異有統(tǒng)計學意義(p0.05)。ckd2期、ckd3期、ckd4期、ckd5期二氧化碳結(jié)合力均值呈下降趨勢,經(jīng)兩兩比較co2-cp均值差異有統(tǒng)計學意義(p0.05)。行血液透析患者二氧化碳結(jié)合力均值低于行腹膜透析患者二氧化碳結(jié)合力均值(22.57±4.58vs25.28±4.41)mmol/l,差異有統(tǒng)計學意義。ckd早期和ckd晚期患者二氧化碳結(jié)合力水平差異有統(tǒng)計學意義。ckd早期與已行腎臟替代治療的患者二氧化碳結(jié)合力水平差異沒有統(tǒng)計學意義。4.比較慢性腎臟病不同分期代謝性酸中毒發(fā)生率情況。ckd1期患者代謝性酸中毒發(fā)生率低于ckd4期、ckd5期和血液透析患者的代謝性酸中毒發(fā)生率,經(jīng)樣本率比較x2檢驗,差異有統(tǒng)計學意義(p0.05)。ckd2~ckd5期代謝性酸中毒發(fā)病率升高,兩兩比較差異均有有統(tǒng)計學意義(p0.05)。血液透析患者發(fā)生代謝性酸中毒的概率高于行腹膜透析患者,差異有統(tǒng)計學意義(p0.05)。5.糖尿病組代謝性酸中毒發(fā)生率高于非糖尿病組(45.07%vs40.04%),差異有統(tǒng)計學意義(p0.05)。糖尿病患者二氧化碳結(jié)合力低于非糖尿病患者(22.07±2.19VS22.18±5.47)mmol/L,差別沒有統(tǒng)計學意義。代謝性酸中毒患者高血壓患病率高于非代謝性酸中毒患者(72.41%VS65.14%),差別有統(tǒng)計學意義(P0.05)。代謝性酸中毒組與非代謝性酸中毒組糖尿病的患病率比較(40.05%VS37.04%),差別無統(tǒng)計學意義(P0.05)。6.代謝性酸中毒組與非代謝性酸中毒組臨床指標比較,代謝性酸中毒組血漿肌酐、尿素氮、胱抑素C、尿酸、鉀離子、氯離子、磷酸根離子濃度及收縮壓更高,血紅蛋白、紅細胞比容、T3、白蛋白、白球比、脂蛋白a、血漿鈣離子濃度更低。以上臨床因素在兩組之間均值差別有統(tǒng)計學意義(P0.05)。7.分析CO2-CP水平與臨床指標的關(guān)系,CO2-CP水平eGFR、Hb、Alb、A/G、脂蛋白a、血鈣呈正相關(guān),CO2-CP水平與收縮壓、Scr、BUN、尿酸、氯離子濃度、磷酸根濃度呈負相關(guān)。8.多因素logistic回歸分析顯示腎小球濾過率下降(OR=2.38,P0.05)、氯離子濃度升高(OR=1.116,P0.05)是慢性腎臟病代謝性酸中毒的危險因素;脂蛋白a濃度升高(OR=0.998,P0.05)是慢性腎臟病代謝性酸中毒的保護因素。結(jié)論:1.代謝性酸中毒是慢性腎臟病常見并發(fā)癥,慢性腎臟病早期甚至CKD1期即可發(fā)生代謝性酸中毒,預防和治療代謝性酸中毒應從慢性腎臟病早期開始。2.慢性腎臟病合并代謝性酸中毒患者高血壓患病率高于慢性腎臟病無代謝性酸中毒患者,代謝性酸中毒可能是慢性腎臟病患者血壓升高或者血壓難以控制的原因之一。3.隨著慢性腎臟病的進展代謝性酸中毒的發(fā)生率呈逐漸升高趨勢,腎小球濾過率下降、血氯濃度升高是慢性腎臟病代謝性酸中毒的危險因素,脂蛋白a濃度升高是慢性腎臟病代謝性酸中毒的保護因素。
[Abstract]:Objective: metabolic acidosis is a common complication of chronic renal disease. Metabolic acidosis can produce a variety of hazards to the human body. The purpose of this study was to study the occurrence of metabolic acidosis in chronic kidney disease and analyze the related factors. Methods: the nephrology department of the Second Affiliated Hospital of Dalian Medical University was selected in the new hospital in September -2016 January 2016. 301 patients, Liaoning renal people's Hospital, Renmin Hospital of Nephrology, 567 new hospitalized patients in December -2016 April 2016. The criteria were diagnosed as chronic renal disease. 1. age 18 years old.2. acute renal failure.3. parathyroidectomy.4. clearly diagnosed the existence of thyroid dysfunction.5. presence of lactic acidosis or ketoacidosis.6. presence Primary renal tubular acidosis. The definition and staging of chronic kidney disease refer to the KDOQI guidelines established by the American kidney disease foundation. Estimate the glomerular filtration rate (eGFR) and use the CKD-EPF (2007) formula. This study analyzed 190 cases of simultaneous blood gas analysis of bicarbonate ion concentration and venous blood carbon dioxide binding force, and the meridional phase The results show that the concentration of bicarbonate has a good positive correlation with the binding force of carbon dioxide, and carbon dioxide binding force can be used as an indicator of metabolic acidosis. Therefore, the carbon dioxide binding force 22 mmol/L is defined as metabolic acidosis. According to the level of carbon dioxide binding force CO2-CP 22-30 mmol/L and CO2-CP22 MMO L/L is divided into a group of non metabolic acidosis and metabolic acidosis. The general information of patients: sex, age, height, weight, BMI, systolic pressure, diastolic pressure, type of primary disease, whether with hypertension, diabetes, calcium antagonists, beta blockers, ACEI/ARB drugs, renal replacement therapy and renal replacement therapy All blood samples were collected on the day of admission, hemodialysis patients were collected before dialysis and electrocardiogram was completed on the day of admission. Blood creatinine, carbon dioxide binding force, HCO3- concentration, hemoglobin, C reactive protein, three iodarine protryptine (T3), thyroxine (T4), thyrotropin (TSH), parathyroid hormone, Total protein, albumin, globulin, white ball ratio, urea nitrogen, Cystatin C, blood uric acid, triglyceride, total cholesterol, high density lipoprotein, low density lipoprotein, lipoprotein a, blood potassium, blood sodium, blood chlorine, blood calcium, blood phosphorus, blood magnesium. Electrocardiogram examination: QT interval, QTc interval. All data were analyzed by SPSS23.0 software. Results: 1. general data: the general data: our research A total of 868 patients were selected, including 447 males, 421 females, age (19~93) years, 47 cases with average age of 63.16 + 14.29 years, 64 cases in ckd2 stage, 83 cases in ckd3 stage, 88 in ckd4 stage, 310 in ckd5 phase, 84 in hemodialysis patients and 192 in peritoneal dialysis. 59 cases of blood pressure, 30 cases of interstitial nephritis, 23 cases of polycystic kidney, 5 cases of gout, 4 cases of systemic lupus erythematosus, 2 cases of urinary tract infection, 2 cases of ANCA related vasculitis, 2 cases of renal cyst, 2 cases of renal cysts, 2 cases of anaphylactoid purpura, and 6 cases of.2. analysis in the other 6 cases: the relationship between carbon dioxide binding force of venous blood and the concentration of bicarbonate ion in blood vessel blood found: carbon dioxide binding The mean value of the force was 18.65 + 5.20mmol/l and the mean concentration of bicarbonate was 19.35 + 5.31mmol/l. The difference was not statistically significant (P0.05) by the independent sample t test. The two groups of measurement data were analyzed in a linear relationship and the Pearson correlation coefficient r=0.933 (p0.001), suggesting that the carbon dioxide binding force was linearly correlated with the concentration of bicarbonate, and the carbon dioxide binding force could be found. As a measure of metabolic acid, this study defined carbon dioxide binding force 22mmol/l as metabolic acidosis.3.. This study was divided into ckd1-5 group according to CKD staging. The mean difference of carbon dioxide binding force among the.7 groups in the hemodialysis group and the peritoneal dialysis group was statistically significant (P0.05). The carbon dioxide junction of the ckd1 patients was compared by 22. The mean value of the combined force was higher than that of the ckd4 stage. The mean value of carbon dioxide binding in ckd5 and hemodialysis patients was statistically significant (P0.05).Ckd2, ckd3, ckd4, and the mean value of carbon dioxide binding force in ckd5 phase decreased, and the difference of co2-cp mean value was statistically significant (P0.05) after 22. The mean of carbon dioxide binding force in hemodialysis patients was lower than that in hemodialysis patients. The mean (22.57 + 4.58vs25.28 + 4.41) mmol/l of carbon dioxide binding force in patients undergoing peritoneal dialysis (22.57 + 4.41), there was significant difference in the level of carbon dioxide binding force between early.Ckd and CKD advanced patients, and there was no statistically significant difference in the level of carbon dioxide binding force between the early.Ckd and the patients who had been treated with renal replacement therapy (.4.). The incidence of metabolic acidosis in different stages of kidney disease in.Ckd1 patients was lower than that in ckd4 stage, and the incidence of metabolic acidosis in ckd5 and hemodialysis patients was compared with x2 test. The difference was statistically significant (P0.05), the incidence of metabolic acidosis in.Ckd2~ckd5 phase increased, and there were 22 different differences in the incidence of metabolic acidosis. There was statistical significance (P0.05). The probability of metabolic acidosis in hemodialysis patients was higher than that in peritoneal dialysis patients. The difference was statistically significant (P0.05) the incidence of metabolic acidosis in.5. diabetic group was higher than that of non diabetic group (45.07%vs40.04%), and the difference was statistically significant (P0.05). Patients (22.07 + 2.19VS22.18 + 5.47) mmol/L, the difference was not statistically significant. The prevalence of hypertension in patients with metabolic acidosis was higher than that of non metabolic acidosis (72.41%VS65.14%), and the difference was statistically significant (P0.05). The prevalence rate of diabetes in the metabolic acidosis group and the non metabolic acidosis group was compared (40.05%VS37.04%). Study significance (P0.05).6. metabolic acidosis group and non metabolic acidosis group clinical indicators, metabolic acidosis group plasma creatinine, urea nitrogen, Cystatin C, uric acid, potassium ion, chloride ion, the concentration of phosphate ion and systolic pressure higher, hemoglobin, erythrocyte specific volume, T3, albumin, white ball ratio, lipoprotein a, plasma calcium concentration more The mean difference between the two groups was statistically significant (P0.05).7. analysis of the relationship between the level of CO2-CP and the clinical indicators, CO2-CP level eGFR, Hb, Alb, A/G, lipoprotein a, positive correlation of blood calcium, CO2-CP level and systolic pressure, Scr, BUN, uric acid, chloride concentration and negative correlation of phosphate concentration The decrease of glomerular filtration rate (OR=2.38, P0.05), the increase of chloride concentration (OR=1.116, P0.05) is a risk factor for the metabolic acidosis of chronic kidney disease; the increase of lipoprotein a (OR=0.998, P0.05) is a protective factor for the metabolic acidosis of chronic kidney disease. Conclusion: 1. metabolic acidosis is a common complication of chronic kidney disease and chronic kidney disease early Metabolic acidosis can occur during the period of CKD1, and the prevention and treatment of metabolic acidosis should start from the early stage of chronic kidney disease with.2. chronic kidney disease and metabolic acidosis, the prevalence of hypertension is higher than that of chronic renal disease without metabolic acidosis. Metabolic acidosis can be the blood pressure rise or blood of patients with chronic kidney disease. One of the reasons why the pressure is difficult to control.3. is gradually increasing with the progression of chronic renal disease. The rate of glomerular filtration is decreasing and the increase of blood chloride concentration is a risk factor for the metabolic acidosis of chronic kidney disease. The increase of lipoprotein a is the protective factor for the metabolic acidosis of chronic kidney disease.
【學位授予單位】：大連醫(yī)科大學
【學位級別】：碩士
【學位授予年份】：2017
【分類號】：R692

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