本文關(guān)鍵詞：腹膜透析對(duì)鐵蛋白清除的臨床研究　出處：《河北醫(yī)科大學(xué)》2015年碩士論文　論文類型：學(xué)位論文

  更多相關(guān)文章： 腹膜透析 鐵蛋白 腎性貧血 感染 殘余腎功能

【摘要】：目的:慢性腎臟病(Chronic kidney disease,CKD)患者隨著腎功能的下降,體內(nèi)促紅細(xì)胞生成素(Erythropoietin,EPO)相對(duì)或者絕對(duì)減少,最終都會(huì)產(chǎn)生腎性貧血(Renal anemia,RA)[1],其發(fā)病率約為40%-60%,是CKD患者常見并發(fā)癥之一[2]。導(dǎo)致腎性貧血的另一重要原因是缺鐵,而血清鐵蛋白(serum ferritin,SF)是鐵在人體內(nèi)的主要儲(chǔ)存形式,其含量變化可作為判斷鐵缺乏和鐵超載的指標(biāo)。常規(guī)使用SF和轉(zhuǎn)鐵蛋白飽和度(Transferrin saturation,TSAT)作為鐵狀態(tài)的評(píng)價(jià)指標(biāo)。既往的腎性貧血指南,包括最新的2013年《腎性貧血診斷與治療中國專家共識(shí)》《腎性貧血診斷與治療中國專家共識(shí)(2014修訂版)》指出:非透析和腹膜透析患者TSAT20%,SF100 ug/L,血液透析患者SF200 ug/L時(shí)開始給予鐵劑治療;SF500 ug/L不常規(guī)應(yīng)用靜脈補(bǔ)鐵治療;TSAT"g50%和(或)SF"g800 ug/L應(yīng)停止靜脈補(bǔ)鐵3個(gè)月。有研究報(bào)道血液透析(hemodialysis,HD)患者中有15%~22%存在絕對(duì)性鐵缺乏,而腹膜透析(Peritoneal dialysis,PD)患者高達(dá)41%~45%存在絕對(duì)性鐵缺乏[3]。2008年底,對(duì)上海市透析患者貧血治療現(xiàn)況進(jìn)行調(diào)查,發(fā)現(xiàn)PD組和HD組貧血治療未達(dá)標(biāo)率分別為60.72%和32.17%,說明仍有相當(dāng)多的患者未達(dá)到治療靶目標(biāo)值,特別是PD組患者未達(dá)標(biāo)率竟達(dá)到一半以上[4]。但是血液透析患者每次透析時(shí),透析管路中或多或少都會(huì)丟失部分血,鐵也會(huì)隨之丟失,理論上應(yīng)比PD患者貧血更不易達(dá)標(biāo),缺鐵更嚴(yán)重,根據(jù)上面的研究顯示,事實(shí)并非如此。PD患者可以通過腹膜透析清除體內(nèi)的毒素,同時(shí)也會(huì)伴有營養(yǎng)物質(zhì)的丟失,這些丟失的物質(zhì)中是否包括鐵蛋白及鐵,鐵蛋白及鐵的丟失是否為PD患者貧血更不易達(dá)標(biāo)及缺鐵更嚴(yán)重的原因,目前相關(guān)研究報(bào)道很少。而且由于到目前還沒有非透析與腹膜透析患者鐵目標(biāo)值的大樣本RCT研究,所以非透析與腹膜透析患者鐵劑治療的目標(biāo)值仍然是一樣的。如果腹膜透析可以清除鐵蛋白及鐵,PD可能比非透析患者缺鐵更嚴(yán)重,同樣的鐵劑治療方案,也許不足以糾正PD患者的貧血。盡管鐵蛋白低說明患者體內(nèi)鐵缺乏,會(huì)出現(xiàn)貧血,但是鐵蛋白升高也會(huì)對(duì)PD患者產(chǎn)生多種危害。國外有研究表明:SF的升高是冠心病(Coronary heart disease,CHD)發(fā)生急性心肌梗死的危險(xiǎn)因素之一[5],而心血管事件是透析患者死亡危險(xiǎn)因素之首。此外最新研究表明,PD患者的殘余腎功能(Residual renal function,RRF)與SF呈負(fù)相關(guān),而且鐵蛋白可加速殘余腎功能的下降[6]。由此可以看出在腹膜透析患者中血清鐵蛋白的濃度與貧血狀況、殘余腎功能、生活質(zhì)量及預(yù)后密切相關(guān),所以我們想通過本實(shí)驗(yàn)進(jìn)一步了解腹膜透析患者中SF的水平與那些因素有關(guān),以及腹膜透析對(duì)血清鐵蛋白的清除情況。方法:選擇2013年5月至2014年11月秦皇島市第一醫(yī)院腎內(nèi)科維持性腹膜透析治療患者25例。搜集患者的一般情況(性別、年齡、身高、體重、體質(zhì)量指數(shù)(Body Mass Index,BMI)、透析齡、腹膜轉(zhuǎn)運(yùn)類型、KT/V、RRF、原發(fā)病、有無感染)。檢測(cè)透析前空腹血紅蛋白(hemoglobin,Hb)、白蛋白(albumin,Alb)、SF、血清鐵(Fe)、轉(zhuǎn)鐵蛋白(transferring,TRF)、肌酐(Creatinine,Cr)、尿素氮(Blood urea nitrogen,BUN)、甲狀旁腺激素(Parathyroid hormone,PTH)。檢測(cè)透析后SF、Fe、TRF、Cr、BUN、PTH。計(jì)算Fe、TRF、Cr、BUN、PTH下降率(Removal rate,RR)。計(jì)錄腹膜透析廢液量,同時(shí)檢測(cè)透析廢液中Fe、TRF、Cr、BUN、PTH的濃度,并計(jì)算其相應(yīng)清除總量(Total removal,TR)作為腹膜透析溶質(zhì)清除的金標(biāo)準(zhǔn)。應(yīng)用SPSS13.0統(tǒng)計(jì)軟件進(jìn)行統(tǒng)計(jì)分析。首先對(duì)透析前SF與年齡、身高、體重、BMI、透析齡、KT/V、RRF、感染、Hb、Alb進(jìn)行兩兩相關(guān)性分析,再進(jìn)行逐步多元線性回歸分析進(jìn)行校正;應(yīng)用配對(duì)T檢驗(yàn)分析透析前后溶質(zhì)濃度變化是否具有統(tǒng)計(jì)學(xué)意義;應(yīng)用Pearson相關(guān)分析透析前SF濃度與腹膜透析廢液中SF濃度及清除總量相關(guān)性;應(yīng)用Spearman秩相關(guān)分析SF與Fe、TRF、Cr、BUN、PTH下降率的相關(guān)性。結(jié)果:1經(jīng)過兩兩相關(guān)分析篩選出感染、RRF、腹膜轉(zhuǎn)運(yùn)類型、Hb、BMI與腹膜透析前SF濃度具有相關(guān)性,進(jìn)一步行逐步多元線性回歸分析進(jìn)行校正得出:透析前SF與感染、RRF有關(guān)(R=0.982,R2=0.964,P0.05),感染、RRF分別用X1、X2來表示,擬合方程為Y^=815.649+740.028X1-476.18X2,F=238.169,P0.001,該擬合方程差異具有計(jì)學(xué)意義。2腹膜透析前后Cr、BUN、PTH、TRF濃度差異具有統(tǒng)計(jì)學(xué)意義(分別的P=0.013、P=0.002、P=0.007、P=0.011)。透析前后SF、Fe濃度差異不具有統(tǒng)計(jì)學(xué)意義(P=0.288、P=0.068)。3腹膜透析液中SF濃度與透析前SF濃度呈正相關(guān)(r=0.636P=0.026)。4腹膜透析液中SF清除總量與透析前SF濃度呈正相關(guān)(r=0.618,P0.05)。5Spearman秩相關(guān)分析表明:SF下降率與Cr、BUN、Fe、TRF、PTH的下降率均不具相關(guān)性(P=0.070、P=0.218、P=0.265、P=0.336)。結(jié)論:1腹膜透析患者中血清鐵蛋白與感染呈正相關(guān),與殘余腎功能呈負(fù)相關(guān)。2腹膜廢液中能夠檢測(cè)到鐵蛋白及鐵離子,透析前血清鐵蛋白濃度與腹膜透析液中的鐵蛋白濃度及其清除總量均呈正相關(guān),說明具有濃度依賴性。3腹膜對(duì)于鐵蛋白的清除不同于肌酐等小分子、也不同于PTH中分子,所以腹膜透析對(duì)鐵蛋白的清除機(jī)制有待進(jìn)一步研究。
[Abstract]:Objective: chronic kidney disease (Chronic kidney, disease, CKD) in patients with decreased renal function, in vivo erythropoietin (Erythropoietin, EPO) the relative or absolute reduction, will eventually produce renal anemia (Renal anemia, RA [1]), the incidence rate is about 40%-60%, CKD is one of the common complications in patients with [2]. Another important reason leading to renal anemia is iron deficiency, and serum ferritin (SF) is the main storage form of iron in human body. Its content change can be used as an index for judging iron deficiency and iron overload. SF and transferrin saturation (Transferrin saturation, TSAT) were used as the criteria for the evaluation of iron status. Renal anemia guidelines of the past, including the latest 2013 "diagnosis and treatment of renal anemia China expert consensus" "diagnosis and treatment of renal anemia Chinese expert consensus (2014 Revision)" pointed out: non dialysis patients and peritoneal dialysis TSAT20%, SF100 ug/L, began treatment of blood dialysis patients given iron SF200 ug/L; iron SF500 ug/L on conventional intravenous; TSAT g50% and G800 ug/L (or SF) "should stop intravenous iron for 3 months. It has been reported that there is absolute iron deficiency in patients with hemodialysis (hemodialysis, HD), while patients with Peritoneal dialysis (PD) are as high as 41%~45%, and there is absolute iron deficiency [3] in patients with 15%~22%. By the end of 2008, Shanghai city conducted a survey of the present situation of anemia in dialysis patients treated, PD group and HD group without anemia treatment compliance rates were 60.72% and 32.17%, there is still a considerable number of patients did not reach the treatment target value, especially the PD group did not meet the rate has reached more than half of [4. However, in hemodialysis patients, more or less blood will be lost in hemodialysis, and iron will also be lost. Theoretically, anemia is more difficult than standard PD, and iron deficiency is more serious. According to the above research, it is not the case. PD by peritoneal dialysis patients can remove toxins from the body, but also accompanied by loss of nutrients, whether these substances include loss of ferritin and iron, ferritin and iron loss is less likely to cause anemia in patients with PD standard and more severe iron deficiency, the related research is rarely reported. And because there is no large sample RCT of non dialysis and peritoneal dialysis patients with iron target value, so non dialysis and peritoneal dialysis in patients with iron target value is still the same. If peritoneal dialysis can remove iron and ferritin, PD may be more severe than non dialysis patients with iron deficiency, iron treatment scheme is the same, may not be sufficient to correct anemia in patients with PD. Although low ferritin indicates iron deficiency in the patient's body, anemia may occur, but the increase of ferritin can also cause a variety of hazards to PD patients. Studies abroad show that the increase of SF is one of the risk factors of Coronary heart disease (CHD), and cardiovascular events are the leading cause of death risk in dialysis patients. In addition, the latest research shows that Residual renal function (RRF) in PD patients is negatively correlated with SF, and ferritin can accelerate the decline of residual renal function [6]. This can be seen in peritoneal dialysis patients with anemia and the concentration of serum ferritin in residual renal function, quality of life and is closely related to the prognosis, so we want to further understand this experiment in peritoneal dialysis patients SF levels associated with those factors, and peritoneal dialysis on serum ferritin clearance. Methods: from May 2013 to November 2014, 25 patients were treated with maintenance peritoneal dialysis in the nephrology department of Qinhuangdao First Hospital. The general condition of patients (gender, age, height, weight, Body Mass Index (BMI), age of dialysis, peritoneal transport type, KT/V, RRF, primary disease and infection) were collected. The fasting hemoglobin (hemoglobin, Hb), albumin (albumin, Alb), SF, serum iron (Fe), transferrin (transferring, TRF), creatinine (Creatinine, Cr), urea nitrogen (Blood Creatinine), and parathyroid hormone were detected before dialysis. SF, Fe, TRF, Cr, BUN and PTH were detected after dialysis. Calculate Fe, TRF, Cr, BUN, PTH drop rate (Removal rate, RR). The amount of peritoneal dialysis waste was counted, and the concentrations of Fe, TRF, Cr, BUN and PTH in dialysis waste were detected. The total clearance amount (Total removal, TR) was calculated as the gold standard for peritoneal dialysis solute clearance. SPSS13.0 statistical software was used for statistical analysis. The pre dialysis SF and age, height, weight, BMI, KT/V, RRF, dialysis age, infection, Hb, Alb 22 correlation analysis, and stepwise multiple linear regression analysis was corrected; using the paired T test to analyze whether the change of solute concentration before and after dialysis had statistical significance; Pearson correlation analysis was used to analyze pre dialysis SF the concentration of SF and peritoneal dialysis effluent concentration and removal of total correlation; correlation using Spearman rank correlation analysis of SF and Fe, TRF, Cr, BUN, PTH decline rate. Results: 1 after 22 related analysis showed that infection, RRF, Hb, BMI, peritoneal transport type and peritoneal dialysis before the SF concentration is relevant for further analysis of the correction of stepwise multiple linear regression: SF and pre dialysis infection, RRF (R=0.982, R2=0.964, P0.05, RRF) infection, respectively X1, X2 that equation is Y^=815.649+740.028X1-476.18X2, F=238.169, P0.001, the fitting equation difference is statistically significant. 2 the concentrations of Cr, BUN, PTH and TRF before and after peritoneal dialysis were statistically significant (P=0.013, P=0.002, P=0.007, P=0.011, respectively). There was no statistically significant difference in the concentration of SF and Fe before and after dialysis (P=0.288, P=0.068). 3 the concentration of SF in Liquor Dialysisintraperitoneus was positively correlated with the concentration of SF before dialysis (r=0.636P=0.026). 4 the total clearance of SF in Liquor Dialysisintraperitoneus was positively correlated with the concentration of SF before dialysis (r=0.618, P0.05). 5Spearman
【學(xué)位授予單位】：河北醫(yī)科大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2015
【分類號(hào)】：R692.5

【引證文獻(xiàn)】

相關(guān)期刊論文 前1條

1 曾海鷗;陳圳煒;羅敏虹;袁麗萍;伍強(qiáng);何東玲;楊鐵城;;透析方式對(duì)非糖尿病終末期腎臟病患者臨床指標(biāo)及胰島素抵抗影響的比較[J];中國血液凈化;2016年04期

，

本文編號(hào)：1343799