本文選題：腹膜透析 + 心臟瓣膜鈣化��； 參考：《蘇州大學(xué)》2014年碩士論文

【摘要】：目的：評估蘇州大學(xué)附二醫(yī)院腹膜透析中心行腹透治療的患者的營養(yǎng)狀態(tài)，血壓水平，鈣磷代謝，生存預(yù)后等情況，研究心臟瓣膜鈣化在腹膜透析患者中的特征，分析心臟主動脈瓣和二尖瓣鈣化發(fā)病可能的危險因素，以及對預(yù)后的影響。 方法：1.選取2006年以后進(jìn)入我腹膜透析中心的117例規(guī)律腹膜透析患者為對象，患者行腹膜透析治療時間均大于18個月。所有患者均由我院心超室進(jìn)行心臟超聲檢查，評估有無主動脈瓣或二尖瓣鈣化，根據(jù)心超結(jié)果分為主動脈瓣鈣化(AVC)陽性組及陰性組，二尖瓣鈣化(MVC)陽性組及陰性組。瓣膜鈣化定義為主動脈瓣、二尖瓣瓣膜或瓣環(huán)出現(xiàn)1個或多個大于1mm的強(qiáng)回聲。收集臨床一般資料，并于清晨采空腹血，記錄血常規(guī)、生化、電解質(zhì)等。患者均于穩(wěn)定狀態(tài)下測定每周總KT/V，腹膜轉(zhuǎn)運功能（PET）。采用橫斷面對比研究分析有瓣膜鈣化組與無瓣膜鈣化組的營養(yǎng)狀態(tài)，透析充分性，鈣磷代謝等指標(biāo)，分析心臟瓣膜鈣化可能的危險因素。 2.選取2009年01月至2011年12月蘇州大學(xué)附屬第二醫(yī)院腹透中心開始透析治療的終末期腎病患者112例，以開始進(jìn)入透析治療為觀察起點，觀察終點為2013年12月31日，隨訪終點事件為死亡或轉(zhuǎn)為血液透析。所有患者均使用1.5%或2.5%葡萄糖腹膜透析液。以開始透析時是否合并心臟瓣膜鈣化分為瓣膜鈣化組及無瓣膜鈣化組。計算患者進(jìn)入透析時有效腎小球濾過率（rGFR）表示殘余腎功能。采用非參數(shù)乘積限估計法（Kaplan-Meier）計算生存率，并用時序檢驗（Log-rank）對同類因素生存率進(jìn)行顯著性檢驗；采用Cox比例風(fēng)險模型進(jìn)行多因素擬合分析及相對危險度(RR）的比較。 3.采用統(tǒng)計軟件SPSS17.0分析，p0.05認(rèn)為有統(tǒng)計學(xué)意義。 結(jié)果：1.（1）共有42例存在心臟瓣膜鈣化，其中單純二尖瓣鈣化4例，單純主動脈鈣化25例，主動脈瓣和二尖瓣雙瓣膜鈣化13例。（2）與無主動脈瓣鈣化組比較，有主動脈瓣鈣化組患者年齡較大，CRP、低密度脂蛋白、總膽固醇較高，高血壓病程較長，高血壓病程與分級乘積數(shù)值較高，而前白蛋白偏低，差異有統(tǒng)計學(xué)意義。而血白蛋白、血紅蛋白、血鈣、血磷、鈣磷乘積、iPTH均無顯著差異。（3）與無二尖瓣鈣化組比較，發(fā)生二尖瓣鈣化的患者年齡較大，透析齡較長，血磷、鈣磷乘積、CRP較高，前白蛋白較低，差異有顯著意義。（4）多因素Logistic回歸分析顯示年齡(每增加10歲）、鈣磷乘積與瓣膜鈣化獨立正相關(guān)，而前白蛋白與心臟瓣膜鈣化獨立負(fù)相關(guān)。（5）進(jìn)一步分別以主動脈瓣鈣化或二尖瓣鈣化為因變量行單因素回歸分析，P0.1的變量選為協(xié)變量進(jìn)入多因素回歸（后向法）分析。年齡/10(OR=1.965，p=0.01)、糖尿病史（OR=4.693，p=0.029）、鈣磷乘積（OR=2.373，p=0.001）、前白蛋白（OR=0.908，p=0.012）與主動脈瓣鈣化獨立相關(guān)；年齡/10(OR=3.179，p=0.023)、鈣磷乘積（OR=6.512，p=0.001）、前白蛋白（OR=0.885，p=0.033）、高密度脂蛋白（OR=19.540，p=0.011）、糖尿病史（OR=6.948，p=0.038）與二尖瓣鈣化獨立相關(guān)。（6）心臟瓣膜鈣化組與無鈣化組比較，左房內(nèi)徑明顯增大，有顯著性差異，射血分?jǐn)?shù)（EF值），E/A值，左室后壁厚度，室間隔厚度等指標(biāo)無顯著差別。室間隔厚度及左室后壁厚度分別與高血壓程度分級有相關(guān)關(guān)系，p0.05；左室舒張內(nèi)徑及左室收縮內(nèi)徑、瓣開放距離、E/A值分別年齡相關(guān)，p0.05。 2.（1）112例患者進(jìn)入透析時有19例患者合并心臟瓣膜鈣化，發(fā)病率16.96%。所有患者平均年齡為58.24±15.23歲，男性69例。在隨訪期間，26例患者死亡，112例患者總體生存時間為50.1±1.7月。（2）利用非參數(shù)乘積限估計法（Kaplan-Meier)計算無瓣膜鈣化組的1年、2年、3年累積生存率分別為90.9%、86.2%、84.7%，有瓣膜鈣化組1年、2年、3年累積生存率分別為89.5%、82.6%、24.1%。經(jīng)Log-Rank檢驗進(jìn)行比較：卡方值=21.126，P0.000，有顯著性差異。（3）校正混雜因素后經(jīng)多因素COX回歸分析提示瓣膜鈣化組死亡風(fēng)險明顯增加，RR=3.319，P=0.022，且獨立于低前白蛋白水平，高齡等因素。 結(jié)論：1.維持性腹膜透析患者心臟瓣膜鈣化多發(fā)，，其中以主動脈瓣鈣化更多見，年齡、糖尿病史、鈣磷乘積、低前白蛋白血癥是主動脈瓣鈣化的獨立危險因素，年齡、鈣磷乘積、低前白蛋白血癥是二尖瓣鈣化的獨立危險因素。 2.進(jìn)入透析時合并心臟瓣膜鈣化的腹透患者具有較高的死亡率，是影響預(yù)后的獨立危險因素。
[Abstract]:Objective: To evaluate the nutritional status, blood pressure level, calcium and phosphorus metabolism and survival prognosis in the peritoneal dialysis center of the two hospital of Soochow University, to investigate the characteristics of cardiac valve calcification in peritoneal dialysis patients and to analyze the possible risk factors of cardiac aortic valve and mitral calcification, as well as the effect on prognosis.
Methods: 1. to select 117 regular peritoneal dialysis patients who entered my peritoneal dialysis center after 2006. The patients were treated with peritoneal dialysis for more than 18 months. All the patients were examined by cardiac ultrasound in our hospital. The calcification of the aortic valve or mitral valve was evaluated, and the aortic valve calcification (AVC) was divided according to the cardiac superresult. Positive group and negative group, mitral valve calcification (MVC) positive group and negative group. Valvular calcification was defined as aortic valve, mitral valve or valve ring appeared 1 or more than 1mm strong echo. Collect clinical general data, collect blood, record blood routine, biochemistry, electrosolution and so on in the early morning. Membrane transport function (PET). A cross-sectional study was used to analyze the nutritional status of valvular calcification group and no valvular calcification group, dialysis adequacy, calcium phosphorus metabolism and other risk factors for cardiac valve calcification.
2. selected 112 patients with end-stage renal disease from the center of The Second Hospital Affiliated to Suzhou University from 01 to December 2011 2009 to begin dialysis treatment to start dialysis treatment as the starting point. The end point was December 31, 2013, the end point of the follow-up was dead or converted to blood dialysis. All patients used 1.5% or 2.5% glucose peritoneum. The dialysate was divided into valvular calcification group and no valvular calcification group at the start of dialysis. The effective glomerular filtration rate (rGFR) was used to calculate the residual renal function during dialysis. The survival rate was calculated by the nonparametric product limit estimation (Kaplan-Meier), and the survival rate of similar factors was measured by time series test (Log-rank). The Cox proportional hazards model was used for multivariate analysis and relative risk (RR) comparison.
3. statistical software SPSS17.0 was used to analyze P0.05.
Results: 1. (1) there were 42 cases of cardiac valve calcification, including pure mitral calcification in 4 cases, simple aortic calcification in 25 cases, aortic valve and mitral valve calcification in 13 cases. (2) compared with the group without aortic valve calcification, the patients with aortic valve calcification were older, CRP, low density lipoprotein, higher total cholesterol, and a longer course of hypertension. There was no significant difference in blood albumin, hemoglobin, hemoglobin, blood calcium, blood phosphorus, calcium and phosphorus product, and no significant difference in iPTH. (3) compared with the non mitral valve calcification group, patients with mitral calcification had older age, longer dialysis age, blood phosphorus, calcium and phosphorus product, higher CRP, anterior white. The difference was significant. (4) multiple factor Logistic regression analysis showed that age (each increase of 10 years), calcium and phosphorus product was independent of valve calcification, and prealbumin was independently associated with cardiac valve calcification. (5) a single factor regression analysis was performed with aortic valve calcification or two apex calcification, and the variable of P0.1 /10 (OR=1.965, p=0.01), diabetes mellitus (OR=4.693, p=0.029), OR=2.373, p=0.001, OR=0.908, p=0.012 are independent of aortic valve calcification; age /10 (OR=3.179, p=0.023), calcium and phosphorus products, prealbumin, OR=19.540 (p=0.011) and diabetes history (OR=6.948, p=0.038) were independent of mitral calcification. (6) compared with the non calcification group, the cardiac valve calcification group was significantly increased in the left atrial diameter, and there were significant differences. There was no significant difference between the ejection fraction (EF), the E/A value, the left ventricular posterior wall thickness, the ventricular septum thickness and so on. The ventricular septal thickness and left ventricular septum thickness were not significant. The thickness of the posterior wall was related to the grade of hypertension, P0.05, the left ventricular diastolic diameter and the left ventricular systolic diameter, the open distance of the valve, and the age correlation of the E/A value respectively, p0.05.
2. (1) 112 patients entered dialysis with 19 patients with cardiac valve calcification. The average age of all patients with 16.96%. was 58.24 + 15.23 years and 69 men. In the follow-up period, 26 patients died and 112 patients had a total survival time of 50.1 + 1.7 months. (2) the non valvular calcification group was calculated by the non parametric product limit estimation (Kaplan-Meier). The cumulative survival rate of 1 years, 2 years and 3 years was 90.9%, 86.2%, 84.7% respectively. The cumulative survival rate of valve calcification group was 1 years, 2 years and 3 years, respectively, 89.5%, 82.6%, 24.1%. were compared by Log-Rank test: Chi square value =21.126, P0.000, significant difference. (3) correction of confounding after multiple factor COX regression analysis suggested that the risk of death in valve calcification group increased significantly Add, RR=3.319, P=0.022, and independent of low prealbumin level, age and other factors.
Conclusion: 1. the cardiac valve calcification in patients with maintenance peritoneal dialysis is more frequent, including more aortic valve calcification, age, diabetes history, calcium and phosphorus product, and low prealbumin as an independent risk factor for aortic valve calcification. Age, calcium and phosphorus product, and hypoalbuminemia are independent risk factors for mitral valve calcification.
2. peritoneal dialysis patients complicated with valvular calcification during dialysis have higher mortality rate and are independent risk factors for prognosis.
【學(xué)位授予單位】：蘇州大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2014
【分類號】：R692.5

【參考文獻(xiàn)】

相關(guān)期刊論文 前1條

1 杜祥穎;李坤成;;鈣化性心臟瓣膜病的影像學(xué)診斷[J];中華老年多器官疾病雜志;2010年01期

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