【摘要】：目的： 探討腹膜透析（peritoneal dialysis，PD）與血液透析（hemodialysis，HD）患者鈣磷代謝異常與心血管鈣化（cardiovascular calcification，CVC）的關系及心血管鈣化對維持性透析患者生存預后的影響；進一步比較腹膜透析和血液透析患者主動脈弓鈣化的差異性和因素，以及透析患者生存預后的影響差異。 方法： 入選2011年1月1日至2013年12月31日期間于上海市第六人民醫(yī)院腹膜透析治療中心和血液透析治療中心進行規(guī)律透析治療的CKD5期患者。收集患者一般透析資料，身高、體重、血壓、生化檢驗等指標，評估患者殘余腎功能和透析充分性，記錄患者胸部X線，評估主動脈弓鈣化（aortic arch calcification，AoAC）程度，記錄腹膜透析患者心超檢查心臟瓣膜鈣化（heart valve calcification，HVC）情況，透析患者用藥情況。采用二元Logistics回歸分析心臟瓣膜鈣化和主動脈弓鈣化獨立危險因素；采用Kaplan-Meier生存分析心血管鈣化對透析患者生存預后的影響；采用多變量COX回歸分析透析患者死亡風險的獨立危險因素；比較腹膜透析和血液透析患者主動脈弓鈣化及生存預后情況，采用Kaplan-Meier生存分析透析主動脈弓鈣化對采用不同透析方式的患者生存預后影響。 結果： 共收入腹膜透析患者177例，心臟瓣膜鈣化病例50例（28.25%），單純二尖瓣鈣化（mitral valve calcification，MVC）11例，單純主動脈瓣鈣化（aortic valvecalcification，AVC）28例，二尖瓣及主動脈瓣均鈣化病例11例，主動脈弓鈣化病例66例（37.29%）。年齡和透析時間是腹膜透析患者心臟瓣膜鈣化、主動脈弓鈣化獨立危險因素（P＜0.01）。血磷、鈣磷乘積是腹膜透析心血管鈣化的獨立危險因素。血磷水平＞2.00mmol/L，心臟瓣膜鈣化和主動脈弓鈣化發(fā)生率明顯增高，與≤1.50mmol/L相比，心臟瓣膜鈣化（OR=4.271，95%CI1.702-10.714，P=0.001），主動脈弓鈣化（OR=10.235，95%CI1.719-10.434，P=0.001）；鈣磷乘積水平＞4.20mmol2/L2時，心臟瓣膜鈣化和主動脈弓鈣化發(fā)生率明顯增高，與≤3.50mmol2/L2比較，心臟瓣膜鈣化（OR=4.296，95%CI1.874-9.852，P=0.000），主動脈弓鈣化（OR=6.750，95%CI3.014-15.118，P=0.000）。鈣磷乘積是影響心臟瓣膜鈣化的強獨立危險因素（HR=2.739，95%CI1.578-4.755，P=0.000）；血磷是影響主動脈弓鈣化的強獨立危險因素（HR=45.167，95%CI8.914-228.850，P=0.000）。糖尿病腎病（diabetic kidney disease，DKD）患者心臟瓣膜和主動脈弓鈣化發(fā)生風險分別是非糖尿病腎病患者的2.677倍和2.127倍。心臟瓣膜鈣化病例生存率明顯低于無瓣膜鈣化者（Log-rank=6.832，P=0.009）；中度(重度)主動脈弓鈣化病例生存率明顯低于無鈣化者（Log-rank=12.035，P=0.002），死亡風險為無鈣化病例的6.167倍（P＜0.01）。 收入血液透析病例147例，，主動脈弓鈣化88例（59.86%）。鈣磷乘積是影響血液透析患者主動脈弓鈣化的強獨立危險因素（HR=2.719，95%CI1.599-4.622，P=0.000）。鈣磷乘積水平＞4.20mmol2/L2時，主動脈弓鈣化發(fā)生率明顯增高，與≤3.50mmol2/L2比較，OR=7.467，95%CI3.306-16.863，P=0.000。糖尿病腎病患者主動脈弓鈣化發(fā)生風險是非糖尿病腎病患者的3.339倍。中度(重度)主動脈弓鈣化病例生存率明顯低于無鈣化者（Log-rank=9.834，P=0.007），死亡風險為無鈣化病例的24.429倍（P＜0.01）。 在透析時間13-36月中，腹透病例主動脈弓鈣化發(fā)生率低于血透病例（33.60%vs55.60%，P=0.025）；殘余腎功能高于血透病例（3.54±3.14ml/min vs1.92±1.38ml/min，P=0.012）；鈣磷乘積水平低于血透病例（4.09±1.06mmol2/L2vs4.75±1.36mmol2/L2，P=0.034）。血透病例中度(重度)主動脈弓鈣化發(fā)生率高于腹透病例（26.53%vs19.77%，OR=2.096，95%CI1.204-3.652，P=0.008）。血透患者中，中度(重度)鈣化病例生存率明顯低于無鈣化者（Log-rank=9.834，P=0.007）。在透析13-36月時間段中，腹透患者生存預后優(yōu)于血透患者（9.70%vs22.20%，P=0.034），中度（重度）主動脈弓鈣化對腹透病例和血透病例之間的影響無明顯差異性（Log-rank=2.938，P=0.086）。 結論： 高血壓、血脂、糖尿病是影響心血管鈣化的傳統(tǒng)危險因素，鈣磷代謝異常是終末期腎病患者心血管鈣化的又一重要危險因素。中度（重度）主動脈弓鈣化是維持性腹膜透析和血液透析患者全因死亡的獨立危險因子，心臟瓣膜鈣化則是腹膜透析患者心血管疾病死亡的獨立危險因子。腹膜透析更好的保護和延緩殘余腎功能的喪失，從而更好的維持鈣磷水平是主動脈弓鈣化發(fā)生率低于血液透析患者的重要因素。中度（重度）主動脈弓鈣化是終末期腎病透析患者死亡風險的強危險因子，但對腹膜透析和血液透析患者的風險影響無明顯差異性。
[Abstract]:Objective:
The relationship between abnormal calcium and phosphorus metabolism and cardiovascular calcification (cardiovascular calcification, CVC) in patients with peritoneal dialysis (PD) and hemodialysis (hemodialysis, HD) and the influence of cardiovascular calcification on survival prognosis of patients with maintenance dialysis, and the difference of aortic arch calcification in peritoneal dialysis and hemodialysis patients. Heterosexual and factors, as well as the difference in survival prognosis of dialysis patients.
Method:
From January 1, 2011 to December 31, 2013, CKD5 patients in the Shanghai No.6 People's Hospital peritoneal dialysis treatment center and the hemodialysis treatment center were selected for regular dialysis treatment. The patients' general dialysis data, height, weight, blood pressure, biochemical test and other indicators were collected to assess the residual renal function and dialysis adequacy, and the patient was recorded. The degree of aortic arch calcification (aortic arch calcification, AoAC) was evaluated in the chest X-ray, and the cardiac valve calcification (heart valve calcification, HVC) in peritoneal dialysis patients was recorded and the medication of the dialysis patients was used. The independent risk factors of cardiac valve calcification and aortic arch calcification were analyzed by two yuan Logistics regression, and Kaplan was used for Kaplan. -Meier survival analysis of cardiovascular calcification on the survival of dialysis patients; multivariate COX regression analysis of independent risk factors for dialysis patients' death risk; comparison of aortic arch calcification and survival prognosis in peritoneal dialysis and hemodialysis patients and the use of Kaplan-Meier survival analysis to analyze the difference in aortic arch calcification. The survival prognosis of patients undergoing dialysis.
Result:
There were 177 cases of peritoneal dialysis, 50 cases of cardiac valve calcification (28.25%), 11 cases of mitral valve calcification (MVC), 28 cases of aortic valve calcification (aortic valvecalcification, AVC), 11 cases of mitral and aortic valve calcification, 66 cases of aortic arch calcification (37.29%). Age and dialysis time were Cardiac valve calcification and aortic arch calcification were independent risk factors (P < 0.01). Blood phosphorus, calcium and phosphorus product was an independent risk factor for cardiovascular calcification in peritoneal dialysis. The level of blood phosphorus was > 2.00mmol/L. The incidence of cardiac valve calcification and aortic arch calcification increased significantly. Compared with 1.50mmol/L, cardiac valve calcification (OR=4.271,95%CI1) .702-10.714, P=0.001), aortic arch calcification (OR=10.235,95%CI1.719-10.434, P=0.001); calcium and phosphorus product level > 4.20mmol2/L2, the rate of cardiac valve calcification and aortic arch calcification increased significantly, compared with < 3.50mmol2/L2, cardiac valve calcification (OR=4.296,95% CI1.874-9.852, P=0.000), aortic arch calcification (OR=6.750,95%CI3.014-15.1). 18, P=0.000). The calcium and phosphorus product is a strong independent risk factor (HR=2.739,95%CI1.578-4.755, P=0.000) affecting cardiac valve calcification; blood phosphorus is a strong independent risk factor for the calcification of the aortic arch (HR=45.167,95%CI8.914-228.850, P=0.000). Cardiac valve and aortic arch calcification in patients with diabetic nephropathy (diabetic kidney disease, DKD) The risk was 2.677 and 2.127 times as high as that of non diabetic nephropathy. The survival rate of heart valve calcification was significantly lower than that of no valvular calcification (Log-rank=6.832, P=0.009); the survival rate of moderate (severe) aortic arch calcification was significantly lower than that of non calcified cases (Log-rank=12.035, P =0.002), and the risk of death was 6.167 times (P < 0.01) (P < 0.01). ).
147 cases received hemodialysis and 88 cases of aortic arch calcification (59.86%). Calcium and phosphorus product was a strong independent risk factor (HR=2.719,95%CI1.599-4.622, P=0.000) affecting the calcification of aortic arch in hemodialysis patients. The incidence of aortic arch calcification increased significantly when calcium and phosphorus product level was > 4.20mmol2/L2, compared with 3.50mmol2/L2, OR=7.467,95%CI3.3 The risk of aortic arch calcification in patients with P=0.000. diabetic nephropathy was 3.339 times as high as that of non diabetic nephropathy. The survival rate of moderate (severe) aortic arch calcification was significantly lower than that of those without calcification (Log-rank=9.834, P=0.007), and the risk of death was 24.429 times as high as that of no calcification cases (P < 0.01).
In 13-36 months of dialysis, the incidence of aortic arch calcification was lower than that of hemodialysis (33.60%vs55.60%, P=0.025). The residual renal function was higher than that of hemodialysis (3.54 + 3.14ml/min vs1.92 + 1.38ml/min, P=0.012), and the level of calcium and phosphorus product was lower than that of hemodialysis (4.09 + 1.06mmol2/L2vs4.75 + 1.36mmol2/L2, P=0.034). The incidence of aortic arch calcification was higher than that of peritoneal dialysis (26.53%vs19.77%, OR=2.096,95%CI1.204-3.652, P=0.008). In hemodialysis patients, the survival rate of moderate (severe) calcification cases was significantly lower than those without calcification (Log-rank=9.834, P=0.007). In the 13-36 month period of dialysis, the survival of the patients with peritoneal dialysis was better than that of the hemodialysis patients (9.70%vs22.20%, P=0.034). There was no significant difference in the severity of aortic arch calcification between patients with peritoneal dialysis and hemodialysis cases (Log-rank=2.938, P=0.086).
Conclusion:
Hypertension, blood lipid, and diabetes are the traditional risk factors for cardiovascular calcification. Abnormal calcium and phosphorus metabolism is another important risk factor for cardiovascular calcification in patients with end-stage renal disease. Moderate (severe) aortic arch calcification is an independent risk factor for the death and death of patients in maintenance peritoneal dialysis and hemodialysis patients. Cardiac valve calcification is the peritoneum. An independent risk factor for the death of cardiovascular disease in dialysis patients. Peritoneal dialysis better protects and delays the loss of residual renal function, thus maintaining a better level of calcium and phosphorus is an important factor in the incidence of aortic arch calcification lower than that of hemodialysis patients. Moderate (severe) calcification of the aortic arch is a strong risk of death in end-stage renal dialysis patients. Risk factors, however, had no significant difference in the risk of peritoneal dialysis and hemodialysis.
【學位授予單位】：蘇州大學
【學位級別】：碩士
【學位授予年份】：2014
【分類號】：R692.5

【共引文獻】

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