本文選題：鈣磷代謝 + 血脂代謝　； 參考：《昆明醫(yī)科大學(xué)》2017年碩士論文

【摘要】：[目的]近年來,隨著慢性腎臟病(chronic kidney disease,CKD)發(fā)病率的增高,終末期腎臟病(end stage renal disease,ESRD)發(fā)病率也逐年升高,盡管血液透析、腹膜透析及腎移植延長了 ESRD患者生存時間,但透析患者死亡率仍明顯升高[1]。ESRD患者常常出現(xiàn)多種并發(fā)癥,如水、酸堿平衡紊亂,鈣磷代謝紊亂,血脂代謝異常,心血管疾病等。已有多項研究證實ESRD患者的高磷血癥和嚴(yán)重繼發(fā)性甲狀旁腺亢進(jìn),可以引起心血管系統(tǒng)并發(fā)癥,如冠狀動脈、心臟瓣膜及大動脈發(fā)生鈣化,且病死率增高[2][3]。而心腦血管疾病是透析患者主要的死亡原因。目前微炎癥狀態(tài)已成為CKD研究領(lǐng)域的熱點之一,有研究指出,炎癥指標(biāo)是維持性血液透析(maintenance hemodialysis,MHD)患者心血管疾病及死亡的預(yù)測因素之一[4]。也有研究指出,持續(xù)性非臥床腹膜透析(continous ambulatory peritoneal dilaysis,CAPD)患者也存在微炎癥狀態(tài),這種微炎癥反應(yīng)一方面會逐漸使腹膜纖維化,腹膜超濾功能衰竭,另一方面會增加心血管事件的風(fēng)險[5]。由此可見MHD和CAPD患者的微炎癥狀態(tài)可能是影響透析患者心血管事情的危險因素之一,這是國內(nèi)外臨床研究者的共識。但對于ESRD透析患者微炎癥狀態(tài)與血脂及鈣磷代謝異常有無相關(guān)性,目前尚無明確定論。有研究顯示:CAPD患者微炎癥因子水平與肌酐、血鈣、血磷、膽固醇水平無關(guān)[6]。也有研究表明MHD患者血(high sensitive C reactive protein,hs-CRP)與總膽固醇、甘油三脂、低密度蛋白膽固醇間呈明顯正相關(guān),與高密度蛋白膽固醇及鈣磷代謝間無明顯相關(guān)性[7]。本研究通過分析透析患者微炎癥狀態(tài)與脂代謝及鈣、磷代謝的相關(guān)性,為透析患者減少并發(fā)癥、延長生命、減少醫(yī)療費(fèi)用尋找有效的方法和途徑,并為今后進(jìn)一步的研究透析患者微炎癥反應(yīng)發(fā)生機(jī)制提供理論依據(jù)。[方法]1.病例資料選取選取昆明醫(yī)科大學(xué)第一附屬醫(yī)院及第二附屬醫(yī)院2015年6月-2016 年 6 月 CAPD 患者 31 例為腹膜透析(peritoneal dilaysis,PD)組:PD 組,男16例,女15例。選取同時期昆明醫(yī)科大學(xué)第一附屬醫(yī)院MHD患者31例為血液透析(hemodialysis,HD)組:HD組,男15例,女16例。另選18名健康志愿者為對照組,男10例,女8例。2.透析方式(1)血液透析血液透析患者使用日本威高透析機(jī),聚砜膜透析器以無糖透析液行碳酸氫鹽透析,透析膜面積1.3～1.7m2,抗凝劑使用普通肝素或低分子肝素,血流量為200～250 m L/min,透析流量為500 m L/min,鉀離子、鈣離子濃度分別為2.0 mmol/1L和1.5mmol/L。透析2～3次/周,3～4h/次,脫水1.5～3.5kg。(2)腹膜透析即給予1.5%或2.5%濃度的乳酸鹽透析液,溶液量為2000 ml/次,每天進(jìn)行腹膜透析時,要在透析過程中至少更換4次腹透液,實行24 h不間斷透析。3.臨床血標(biāo)本收集用化學(xué)發(fā)光免疫分析法檢測hs-CRP、血甲狀旁腺素。全自動生化分析儀檢測血肌酐、尿素氮,總膽固醇、高密度脂蛋白膽固醇、低密度脂蛋白膽固醇、甘油三酯、血鈣、血磷等。4.統(tǒng)計方法用統(tǒng)計方法分析各個觀察指標(biāo),P0.05為差異有統(tǒng)計學(xué)意義。[結(jié)果]1.HD組患者血鈣的達(dá)標(biāo)率為45.2%,PD組患者血鈣達(dá)標(biāo)率為16.1%,HD患者血鈣達(dá)標(biāo)率高于PD組患者,差異有統(tǒng)計學(xué)意義(P0.05);而PD組患者血磷達(dá)標(biāo)率(45.2%)、甲狀旁腺素達(dá)標(biāo)率(51.6%)高于HD組患者血磷達(dá)標(biāo)率(32.3%)、甲狀旁腺素達(dá)標(biāo)率(32.3%),但差異無統(tǒng)計學(xué)意義(P0.05)。2.HD組患者總膽固醇達(dá)標(biāo)率(96.8%)、低密度脂蛋白膽固醇達(dá)標(biāo)率(93.5%)、甘油三酯達(dá)標(biāo)率(80.6%)高于PD組患者總膽固醇達(dá)標(biāo)率(90.3%)、低密度脂蛋白膽固醇達(dá)標(biāo)率(90.3%)、甘油三酯達(dá)標(biāo)率(71.0%);高密度脂蛋白膽固醇達(dá)標(biāo)率(38.7%)低于PD組患者高密度脂蛋白膽固醇達(dá)標(biāo)率(54.8%),但差異均無統(tǒng)計學(xué)意義(P0.05)。3.與正常對照組相比,HD組患者及PD組患者的血hs-CRP升高,差異有統(tǒng)計學(xué)意義(P0.05),但HD組患者與PD組患者的血hs-CRP相比,差異無統(tǒng)計學(xué)意義(P0.05)。4.HD組患者總膽固醇、血鈣、血磷、血甲狀旁腺激素及鈣磷乘積較正常對照組升高,高密度脂蛋白膽固醇較正常組下降,差異均有統(tǒng)計學(xué)意義(P0.05);而甘油三脂及低密度脂蛋白膽固醇與正常對照相比較差異無明顯統(tǒng)計學(xué)意義(P0.05)。5.PD組患者總膽固醇、血磷、血甲狀旁腺激素及鈣磷乘積較正常對照組升高,血鈣較正常對照組下降,差異均有統(tǒng)計學(xué)意義(P0.05);高密度脂蛋白膽固醇、甘油三脂及低密度脂蛋白膽固醇與正常對照相比差異無明顯統(tǒng)計學(xué)意義(P0.05)。6.HD組患者與PD組患者的總膽固醇、甘油三酯、低密度脂蛋白、高密度脂蛋白、血鈣、血磷、鈣磷乘積、甲狀旁腺激素差異無明顯統(tǒng)計學(xué)意義(P0.05)。7.PD組患者甘油三脂與hs-CRP具有正相關(guān)性(r=0.36,P0.05),其余血脂及鈣磷代謝指標(biāo)與hs-CRP均無明顯相關(guān)性(P0.05);HD組患者血脂代謝及鈣磷代謝指標(biāo)與hs-CRP均無明顯相關(guān)性(P0.05)。[結(jié)論]長期透析患者存在微炎癥狀態(tài),同時伴有血脂代謝紊亂及鈣磷代謝異常,但微炎癥反應(yīng)與透析患者血脂及鈣磷代謝沒有顯著相關(guān)性。
[Abstract]:[Objective] in recent years, with the increase of the incidence of chronic renal disease (chronic kidney disease, CKD), the incidence of end-stage renal disease (end stage renal disease, ESRD) is also increasing year by year. Although hemodialysis, peritoneal dialysis and renal transplantation extend the survival time of ESRD patients, the mortality rate of dialysis patients is still significantly higher than that of [1].ESRD patients. There are many complications, such as water, acid-base balance disorder, disorder of calcium and phosphorus metabolism, abnormal metabolism of blood lipid, cardiovascular disease, and so on. Many studies have confirmed that hyperphosphoremia and severe secondary hyperparathyroidism in ESRD patients can cause cardiovascular system complications, such as coronary artery, heart valve and large artery calcification, and the fatality rate increases [2] [3]. and cardiovascular and cerebrovascular diseases are the main causes of death in dialysis patients. Microinflammation has become one of the hotspots in the field of CKD research. Studies have shown that the inflammatory index is one of the predictors of cardiovascular disease and death in patients with maintenance hemodialysis (MHD), and [4]. has also been studied. There is also a state of micro inflammation in patients with continous ambulatory peritoneal dilaysis (CAPD). This micro inflammatory reaction will gradually make peritoneal fibrosis, peritoneal ultrafiltration failure, and the risk of cardiovascular events increase on the other, [5]. can be found that the micro inflammatory state of MHD and CAPD patients may affect the heart of dialysis patients. One of the risk factors of vascular events is the consensus of clinical researchers at home and abroad. However, there is no definite correlation between the microinflammatory state of ESRD dialysis patients and the abnormal metabolism of blood lipids and calcium and phosphorus. Studies have shown that the levels of microinflammatory factors in CAPD patients are not related to creatinine, blood calcium, blood phosphorus, and cholesterol levels [6]. also have been studied. MHD patients' blood (high sensitive C reactive protein, hs-CRP) is positively correlated with total cholesterol, glycerol three fat, low density protein cholesterol, and no significant correlation with HDL cholesterol and calcium and phosphorus metabolites [7]. based on the analysis of the correlation between the symptoms of hemodialysis patients and lipid metabolism, calcium and phosphorus metabolism, for dialysis patients. To reduce complications, prolong life, reduce medical costs and find effective ways and ways, and provide a theoretical basis for further research on the pathogenesis of micro inflammation in patients. [methods]1. case data were selected and selected to select the First Affiliated Hospital of Kunming Medical University and the two Affiliated Hospital of Kunming Medical University in June June 2015, -2016, in June. 31 cases were peritoneal dilaysis (PD) group: group PD, 16 male and 15 female. 31 cases of MHD patients at the First Affiliated Hospital of Kunming Medical University were selected as hemodialysis (HD) group: HD group, 15 male and 16 female. Another 18 healthy volunteers were selected as group, 10 male, 8 case of.2. dialysis (1) hemodialysis and hemodialysis patients Using the Japanese high altitude dialyzer, the polysulfone membrane dialyzer took the bicarbonate dialysis with sugar free dialysate, the area of the dialysis membrane was 1.3 ~ 1.7m2, the anticoagulant used ordinary heparin or low molecular weight heparin, the blood flow rate was 200~250 m L/min, the dialysis flow rate was 500 m L/min, the potassium ion, the concentration of calcium ion was 2 mmol/1L and 1.5mmol/L. dialysis 2~3 times per week respectively, 3 To 4h/ times, 1.5 to 3.5kg. (2) peritoneal dialysis was dehydrated to give 1.5% or 2.5% concentration of lactate dialysate, the volume of the solution was 2000 ml/ times. At least 4 peritoneal dialysis fluids were replaced during dialysis every day, and 24 h uninterrupted dialysis.3. clinical blood samples were collected by chemiluminescent immunoassay for detection of hs-CRP and parathyroid glands. Serum creatinine, urea nitrogen, total cholesterol, high density lipoprotein cholesterol, low density lipoprotein cholesterol, triglyceride, blood calcium, blood phosphorus and other.4. statistical methods were used to analyze the various observation indexes by the total automatic biochemical analyzer. The difference of P0.05 was statistically significant. [results of group]1.HD, the standard rate of blood calcium in group]1.HD was 45.2%, group PD patients. The rate of blood calcium standard was 16.1%, the standard rate of blood calcium in HD patients was higher than that in PD group, and the difference was statistically significant (P0.05), while in group PD, the standard rate of blood phosphorus was (45.2%), parathyroid hormone standard rate (51.6%) was higher than that of HD group (32.3%) and parathyroid hormone (32.3%), but the difference was not statistically significant (P0.05) the total cholesterol of.2.HD group. The standard rate (96.8%), low density lipoprotein cholesterol standard rate (93.5%), triglyceride standard rate (80.6%) higher than the PD group total cholesterol standard rate (90.3%), low density lipoprotein cholesterol standard rate (90.3%), triglyceride standard rate (71%), high density lipoprotein cholesterol level (38.7%) lower than the PD group of high density lipoprotein cholesterol The standard rate (54.8%), but the difference was not statistically significant (P0.05).3. compared with the normal control group, the blood hs-CRP of the patients in group HD and PD was higher, the difference was statistically significant (P0.05), but there was no statistically significant difference between the HD group and the PD group (P0.05).4.HD group (P0.05).4.HD group, total cholesterol, blood calcium, blood phosphorus, and parathyroid hormone and parathyroid hormone. The product of calcium and phosphorus was higher than that in the normal control group, and the high density lipoprotein cholesterol was lower than that of the normal group. The difference was statistically significant (P0.05), while the difference of the glycerol three fat and low density lipoprotein cholesterol was not statistically significant (P0.05) the total cholesterol, blood phosphorus, parathyroid hormone and calcium phosphorus in the group.5.PD group were more than that of the normal group. The blood calcium was lower in the normal control group than in the normal control group. The difference was statistically significant (P0.05). There was no significant difference between the high density lipoprotein cholesterol, glycerin three fat and low density lipoprotein cholesterol (P0.05) the total cholesterol, triglyceride, low density lipoprotein, and high density in group.6.HD and PD patients. There was no significant statistical significance in the product of DHA, blood calcium, blood phosphorus, calcium and phosphorus (P0.05) in group.7.PD, and there was a positive correlation between glycerol three and hs-CRP (r=0.36, P0.05), and there was no significant correlation between the other blood lipids and calcium and phosphorus metabolism index (P0.05), and there was no significant difference in blood lipid metabolism, calcium and phosphorus metabolism index and hs-CRP in HD group. Correlation (P0.05). [Conclusion] there is a state of microinflammation in long-term dialysis patients, accompanied by metabolic disorders of blood lipids and abnormal calcium and phosphorus metabolism, but there is no significant correlation between the microinflammatory response and the metabolism of blood lipids and calcium and phosphorus in dialysis patients.

【學(xué)位授予單位】：昆明醫(yī)科大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2017
【分類號】：R692.5

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