腹膜透析合并腹壁疝的危险因素及预后

目的分析腹膜透析（peritoneal dialysis,PD）合并腹壁疝人群的临床特点及影响其预后的相关危险因素。方法入选上海交通大学医学院附属瑞金医院肾脏科2006～2011年PD治疗的436例患者。收集基线情况、手术史、置管方式、实验室检查、透析剂量、透析充分性参数等。记录腹壁疝发生时间、部位、类型和治疗方案。根据有无腹壁疝分为A（对照组）、B（腹壁疝组）两组,比较两组的临床特点。应用Logistic回归分析PD患者合并疝的危险因素。结果 27例患者（6.2%）累计发生疝30例次,疝发生率0.054次/患者年,首次疝发生时间为开始PD治疗后（21.86±27.58）周。腹股沟疝22例（81.48%）（双侧4例、右侧12例、左侧6例）;切口疝2例（7.4%）;脐疝2例（7.4%）;多重疝1例（3.7%）。A（n=409）、B（n=27）,2组糖尿病（27.62%比22.22%）、多囊肾（1.5%比0）、腹腔镜置管比例（8.31%比18.51%）无显著差异（P〉0.05）。B组患者平均年龄（59.33±17.73岁比65.07±13.27岁）;男性比例（54.27%比85.16%）和既往盆腹腔手术率（19.32%比37.04%）均高于A组（P〈0.05）。B组平均体质量指数（body mass index,BMI）则明显低于A组（22.53±3.52比20.96±2.38P〈0.05）。2组基线时各项化验检查和初次透后评估结果,如血糖、尿素氮、白蛋白、血红蛋白、血钙、血磷、铁蛋白、甲状旁腺激素、胆固醇、Kt/V、血肌酐、透析剂量、自动腹膜透析（automated peritoneal dialysis,APD）使用率均无明显差异（P〉0.05）,但B组血肌酐（697.00±370.50μmol/L比545.50±338.75μmol/L,P〈0.05）和三酰甘油水平（1.56±1.24mmol/L比0.98±0.92mmol/L,P〈0.05）均明显低于A组。进一步采用Lo-gistic回归分析后发现血肌酐（OR=0.993,95%CI：0.987～0.99,P=0.040）和三酰甘油水平（OR=0.084,95%CI：0.008～0.893,P=0.041）与腹壁疝发生率呈明显负相关。B组患者接受补片修补术7例,复发2例;术后继续PD5例（APD2例）,转HD2例。非手术治疗20例,疝加重1例;继续维持PD17例,肾移植2例,转HD1例。结论腹股沟疝是PD最常见的腹壁疝类型。盆腹腔手术史、体型瘦小、老年男性、营养状况差是PD合并疝的危险因素。

Risk factors and prognosis of peritoneal dialysis patients complicated with abdominal wall hernia

Objective To investigate the risk factors and outcome of the peritoneal dialysis（PD） patients with abdominal wall hernia.Methods We recruited 436 PD patients from Shanghai Ruijin Hospital.Baseline characteristics and follow-up data were recorded.The participants were divided into group A（normal group,n = 409） and group B（hernia group,n = 27） based on whether abdominal wall hernia occurred.Logistic regression analysis was performed.Results The rate of hernia was 6.2%（30 events）.The incidence of hernia was 0.054 times/patient-year,and the average time of first hernia was 21.86 ± 27.58 weeks after PD.Among the hernia patients,22 were inguinal hernia（81.48%）,2 were incisional hernia（7.4%）,2 were umbilical hernia（7.4%）,and 1 was multiple hernia（3.7%）.Patients with diabetes（27.62% vs.22.22%）,polycystic kidney disease（1.5% vs.0） and laparoscopic implantation of catheter（8.31% vs 18.51%） were similar between the two groups.Patients in group A were younger（59.33 ± 17.73year vs 65.07 ± 13.27year）,and had less males（54.27% vs 85.16%）,less abdominal surgery history（19.32% vs.37.04%）,and higher body mass index（BMI）（22.53±3.52 vs.20.96±2.38） than group B（P0.05）.The two groups were similar in baseline characteristics,except that patients in group B had lower serum creatinine（545.50 ± 338.75 μmol/L vs.697.00 ± 370.50 μmol/L） and triglycerides（0.98 ± 0.92 mmol/L vs.1.56 ± 1.24 mmol/L） than group A.Serum creatinine（OR=0.993,P =0.040） and triglyceride（OR=0.084,P =0.040） were negatively correlated with hernia.Conclusion Inguinal hernia is the most common type of abdominal wall hernia in PD patients.Previous abdominal surgery,smaller body size,older male and poor nutritional status were the risk factors for PD patients complicated with hernia.