腹膜透析患者的转归及其危险因素分析

目的分析单中心27年间所有维持性腹膜透析患者的转归,探寻腹膜透析患者死亡的危险因素,讨论减少腹膜透析患者退出的策略。方法回顾性观察解放军第四五五医院自1985年1月开展第1例腹膜透析以来至2011年12月间所有行腹膜透析管置入术开始腹膜透析的患者,并除外维持性腹膜透析不足1月者。记录患者的转归及退出腹膜透析的原因,分析他们的人口学资料、实验室数据、透析充分性、残余肾功能、腹膜转运特性、营养状况等。结果共841例腹膜透析患者入选本研究,其中女性431例(51.2%)。开始腹膜透析时的平均年龄为58.53±16.67岁。原发病中慢性肾小球肾炎占第1位,为441例(52.4%),其次为高血压肾损害149例(17.7%),糖尿病肾病121例(14.4%)。患者的平均腹膜透析龄为18.63±20.35月。至2011年12月底,继续腹膜透析246例(29.2%),死亡296例(35.2%),转血液透析152例(18.1%),肾移植64例(7.6%),失访83例(9.9%)。心血管事件是首位死亡原因(41.6%);其次为感染(33.0%),包括肺部感染(23.2%)和腹膜炎(9.8%);第3位死亡原因是脑血管事件(9.5%)。转血液透析的最主要原因为腹膜透析相关感染(59.2%);然后是导管功能障碍(堵管、漂管等,25.7%);透析不充分(7.2%)。经COX回归模型分析提示,死亡的危险因素是老龄(HR:1.06,P<0.01);糖尿病(HR:1.88,P<0.01);血液透析转至腹膜透析(HR:1.49,P<0.01);低白蛋白血症(HR:2.44,P<0.01);血C反应蛋白增高(HR:2.07,P<0.01);低肌酐清除率(HR:1.89,P<0.05);腹膜高转运状态(HR:2.28,P<0.01)。结论在我中心,腹膜透析患者退出的最主要原因是死亡,其次是转至血液透析。心血管事件是第1位的死亡原因,腹膜透析相关感染是转血液透析的最主要原因。老龄、糖尿病、由血液透析转至腹膜透析、营养不良、炎症状态、透析不充分、腹膜高转运状态者有着更高的死亡风险。

The analysis of outcome and the risk factors for mortality in peritoneal dialysis patients

Objective To analyze the outcome and the risk factors for mortality in the peritoneal dialysis（PD） patients in a single peritoneal dialysis in a period of 27 years,and to discuss the approaches to obtain a better prognosis.Methods We retrospectively analyzed patients on PD for more than one month during the period from January 1985 to December 2011 in this hospital.We collected and analyzed their outcomes,the cause of dropout from PD,demographic characteristics,laboratory data,dialysis adequacy,residual renal function,peritoneal transport characteristics,and nutritional status.Results A total of 841 patients were enrolled,of whom 431 were females（51.2%）.The mean age at the begining of PD was 58.53 ± 16.67 years.The primary diseases for end stage renal disease were glomerulonephritis（52.3%）,hypertension（16.6%）,and diabetes（15.3%）,in which glomerulonephritis was the most important primary disease.The mean peritoneal dialysis duration was 18.63 ± 20.35 months.Up to December 2011,the patients remained on PD in 246 cases（29.2%）,died in 296 cases（35.2%）,changed to hemodialysis in 152 cases（18.1%）,treated with kidney transplant in 64 cases（7.6%）,and lost for follow-up in 83 cases（9.9%）.The main cause of death was cardiovascular events（41.6%）,followed by infection（33.0%） including pulmonary infection（23.2%） and peritonitis（9.8%）,and cerebral vascular accident（9.5%）.The major reason（59.2%） changing from PD to hemodialysis was the PD associated infection,followed by functional abnormalities of peritoneal catheter（25.7%） such as occlusion and drift,and insufficient peritoneal dialysis（7.2%）.Cox proportional hazards model analysis indicated that the risk factors for mortality were age（HR：1.06,P 0.01）,diabetes（HR：1.88,P 0.01）,change of hemodialysis to PD（HR：1.49,P 0.01）,lower serum albumin（HR：2.44,P0.01）,higher C-reaction protein（HR：2.07,P0.01）,lower creatinine clearance rate（HR：1.89,P 0.05）,and higher peritoneal transport status（HR：2.28,P 0.01）.Conclusions In our peritoneal dialysis center,the major cause of dropout from PD was death,followed by the change to hemodialysis.Cardiovascular event was the most important cause of death,and PD-associated infection was the major reason for the change from PD to hemodialysis.Older age,diabetes,malnutrition,inflammation,insufficient peritoneal dialysis,higher peritoneal transport status and change of dialysis from hemodialysis to PD predicted the higher risk for all cause-death.