發(fā)布時間：2018-04-28 22:27

  本文選題：血液透析 + 尿毒癥　； 參考：《吉林大學》2014年碩士論文

【摘要】：背景：終末期腎病在全世界的發(fā)病率呈增高趨勢，且病程長，治療花費高，給個人及社會造成了巨大的負擔，現已然成為重要的公共醫(yī)療問題。血液透析作為ESRD患者的主要腎臟替代治療方法之一，近年來盡管在技術上取得了飛速的進步，但MHD患者的長期生存率和生活質量仍然不高，且各種急慢性并發(fā)癥較多。其中不良心血管事件作為MHD患者的各系統(tǒng)并發(fā)癥之一，嚴重影響患者的預后。 目的：通過對MHD患者進行心臟超聲檢查，發(fā)現有心臟結構及功能變化者，并對影響其發(fā)生發(fā)展的相關因素進行分析，從而方便在臨床上對于相關因素進行有效的干預，以提高MHD患者的長期存活率及生活質量。 方法：選取2013年1月至2014年1月于吉林大學第一醫(yī)院腎病科行維持性血液透析并進行心臟超聲檢查的患者。篩選出符合標準的MHD患者（年齡≥18歲，透析齡＞3個月；排除既往有原發(fā)性心臟疾病、腫瘤疾病及近期發(fā)生急性感染的患者）178例。按照心臟彩超提示的有無心臟改變，，將研究對象分為有心臟改變及無心臟改變兩組。記載每組患者的一般資料、相關生化指標及心臟超聲結果。運用SPSS18.0軟件進行數據的統(tǒng)計分析。計數資料組間比較采用卡方檢驗；計量資料符合正態(tài)分布的組間比較采用t檢驗，不符合正態(tài)分布的組間比較采用非參數檢驗，P＜0.05表示差異有統(tǒng)計學意義。兩組研究指標進行上述比較后，將差異有統(tǒng)計學意義的相關指標進行多因素logistic回歸分析，被回歸方程接受者為影響心臟結構及功能的獨立危險因素。對于上述獨立危險因素診斷心臟改變的方法繪制Roc曲線，從而得出每種危險因素對心臟結構及功能變化有意義的最佳臨界值（靈敏度，特異度）及相對應的曲線下面積（area under curve，AUC）。AUC可代表診斷的準確性，AUC越大，診斷的準確性越高。應用與研究心臟改變相關因素相同的方法，分析心臟改變中發(fā)生率最高的左室舒張功能減退的相關因素。 結果：178例維持性血液透析患者中，發(fā)生心臟結構及功能改變者共120例，占總人數的67.4%。其中發(fā)生左室舒張功能減退者最多，共96例，占總人數的53.9%。 應用相關檢驗方法比較后，透析齡、鐵蛋白、血磷、及鈣磷乘積的差異有統(tǒng)計學意義（P＜0.05）。將以上指標建立多因素Logistic回歸方程，其中透析齡、鐵蛋白及血磷被回歸方程接受，表明上述三個指標高皆為MHD患者心臟結構及功能改變的獨立危險因素。進一步對以上三個指標預測心臟改變的診斷方法繪制ROC曲線，得出診斷心臟改變的最佳臨界值，透析齡36.00個月（靈敏度0.850，特異度0.655），AUC0.859；鐵蛋白：420.00ug/L（靈敏度0.917，特異度0.469），AUC0.729；血磷:1.74mmol/L（靈敏度0.950，特異度0.655），AUC0.782。 收縮壓高為MHD患者發(fā)生左室舒張功能減退的獨立危險因素。對收縮壓預測左室舒張功能減退的診斷方法繪制ROC曲線，得出診斷左室舒張功能減退的最佳臨界值為137.50mmHg （靈敏度0.813，特異度0.561），AUC0.737。 結論：維持性血液透析患者心血管疾病的患病率較高，其中發(fā)生左室舒張功能減退者最多。高透析齡、高鐵蛋白及高血磷皆為MHD患者心臟改變的獨立危險因素。MHD患者透析齡≥36.00個月、鐵蛋白≥200ug/L或血磷≥1.74mmol/L皆可作為預測心臟改變的方法，且這兩種診斷方法均有一定的準確性，其正確判斷心臟改變的百分率分別為：85.0%、91.7%、95.0%；正確判斷非心臟改變的百分率分別為：65.5%、46.9%、65.5%。 收縮壓高為MHD患者左室舒張功能減退的獨立危險因素。MHD患者收縮壓≥137.50mmHg可作為診斷左室舒張功能減退的方法，此種方法有一定的準確性，其正確判斷左室舒張功能減退的百分率為81.3%；正確判斷非心臟改變的百分率分別為：56.1%。
[Abstract]:Background: the incidence of end-stage renal disease is increasing in the world, with a long course of disease, a high cost of treatment and a huge burden on individuals and society. It has become an important public medical problem. Hemodialysis is one of the major renal replacement therapies for ESRD patients. In recent years, rapid progress has been made in technology, However, the long-term survival rate and quality of life of MHD patients are still not high, and there are many acute and chronic complications. The adverse cardiovascular events, as one of the systemic complications of MHD patients, seriously affect the prognosis of the patients.
Objective: through the echocardiographic examination of MHD patients, the changes of cardiac structure and function were found and the related factors affecting their development were analyzed so as to facilitate the effective intervention of the related factors in clinical practice so as to improve the long-term survival rate and the quality of life of the patients with MHD.
Methods: from January 2013 to January 2014, patients with maintenance hemodialysis and echocardiography in Department of nephropathy of No.1 Hospital of Jilin University were selected to select MHD patients (age 18 years old, dialysis age > 3 months), and 178 patients with primary heart disease, swelling disease and recent acute infection were excluded. Two groups were divided into two groups: heart change and no heart change. The general data of each group, related biochemical indexes and cardiac ultrasound results were recorded. Statistical analysis of data was carried out by SPSS18.0 software. T test was used in the comparison of states distribution, and non parametric tests were used in groups that did not conform to normal distribution, and P < 0.05 indicated that the difference was statistically significant. The two groups of research indicators carried out multiple factors logistic regression analysis with statistically significant correlation indexes, and the recipients of the regression equation affected the heart structure. The independent risk factors of the function. Draw the Roc curve for the above independent risk factors for the diagnosis of cardiac changes, thus obtaining the best critical value (sensitivity, specificity) and the area under the corresponding curve (area under curve, AUC).AUC for the diagnostic accuracy of each risk factor, AUC. AUC The more accurate, the higher the accuracy of the diagnosis. The same method used to study the related factors of heart change was used to analyze the related factors of the highest incidence of left ventricular diastolic dysfunction in cardiac changes.
Results: among the 178 patients with maintenance hemodialysis, there were 120 cases of cardiac structure and function change, which accounted for the largest number of 67.4%. in the total number of left ventricular diastolic dysfunction, which accounted for 96 cases, which accounted for the total number of 53.9%..
The differences in age, ferritin, blood phosphorus, and calcium and phosphorus products were statistically significant (P < 0.05). The above index was used to establish a multiple factor Logistic regression equation, in which the age of dialysis, ferritin and blood phosphorus were accepted by the regression equation, indicating that the above three indexes were all independent of the changes of cardiac structure and function in MHD patients. Risk factors. Further the ROC curve was plotted for the diagnosis of cardiac changes by the above three indicators, and the best critical value for the diagnosis of cardiac changes, 36 months of dialysis age (sensitivity 0.850, specificity 0.655), AUC0.859; ferritin: 420.00ug/L (sensitivity 0.917, specificity 0.469), AUC0.729; blood phosphorus: 1.74mmol/L (sensitivity 0.950) Degree 0.655), AUC0.782.
An independent risk factor for the onset of left ventricular diastolic dysfunction in MHD patients. The ROC curve was plotted for the diagnostic method of systolic pressure to predict left ventricular diastolic dysfunction, and the best critical value for the diagnosis of left ventricular diastolic dysfunction was 137.50mmHg (sensitivity 0.813, specificity 0.561), AUC0.737.
Conclusion: the incidence of cardiovascular disease in patients with maintenance hemodialysis is higher, among which left ventricular diastolic dysfunction is the most. High dialysis age, high ferritin and high blood phosphorus are the independent risk factors of cardiac change in MHD patients. The dialysis age of patients with.MHD is more than 36 months. Ferritin > 200ug/L or blood phosphorus more than 1.74mmol/L can be used as predictive heart. The two methods of diagnosis were accurate, and the percentage of correct judgments of cardiac changes were 85%, 91.7%, 95%, and the percentage of non cardiac changes was 65.5%, 46.9%, 65.5%., respectively.
The independent risk factor for left ventricular diastolic dysfunction in MHD patients with systolic and diastolic dysfunction.MHD patients with systolic pressure more than 137.50mmHg can be used as a diagnostic method for left ventricular diastolic dysfunction. This method has certain accuracy. The percentage of the correct judgement of left ventricular diastolic dysfunction is 81.3%; the percentage of non cardiac changes is correctly judged to be 56 .1%.

【學位授予單位】：吉林大學
【學位級別】：碩士
【學位授予年份】：2014
【分類號】：R692.5

【參考文獻】

相關期刊論文 前10條

1 趙慧穎;黃雯;;維持性血液透析患者心臟結構功能變化及相關因素分析[J];北京醫(yī)學;2011年02期

2 左力,王梅,魏弘,馮麗麗;血液透析患者體液分布異常及透析對體液分布的影響[J];北京大學學報(醫(yī)學版);2005年05期

3 錢英俊;羅麗紅;范偉峰;牛建英;顧勇;;長期代謝性酸中毒對維持性血液透析患者微炎癥狀態(tài)的影響[J];當代醫(yī)學;2009年36期

4 徐子欣;陳俊明;;殘余腎功能對維持性血透患者心功能的影響[J];廣西醫(yī)科大學學報;2008年01期

5 廖華偉;任敏;樊雷;涂莉榮;劉曉惠;張和平;張捷;;不同透析方式對終末期腎病患者心血管并發(fā)癥的影響[J];華西醫(yī)學;2009年06期

6 滕蘭波;常明;劉書馨;張運剛;王雪娜;;維持性血液透析患者發(fā)生不良心血管事件危險因素的分析[J];中國中西醫(yī)結合腎病雜志;2010年11期

7 劉磊;張奕民;王身菊;;定量組織速度顯像技術評價慢性腎功能不全血液透析患者左室不同步運動的研究[J];臨床超聲醫(yī)學雜志;2008年05期

8 李清芹;王玉新;陸元善;徐琴君;;106例血液透析患者心血管疾病的危險因素分析[J];臨床內科雜志;2006年06期

9 彭斌;許濤;盛曉華;劉鶯;汪年松;;維持性血液透析患者鈣磷代謝及透析齡與左心室心肌質量指數的關系[J];中國中西醫(yī)結合腎病雜志;2013年09期

10 杜金云;重組人紅細胞生成素對左心室肥厚的影響[J];臨床薈萃;1998年02期

本文編號：1817168