Effects of serum magnesium level on mortality in maintenance hemodialysis patients

Objective To investigate the effects of serum magnesium level on all-cause mortality and cardiovascular and cerebrovascular diseases mortality in maintenance hemodialysis (MHD) patients. Methods Clinical data of MHD patients in Shaoxing People's Hospital from June 1, 2016 to June 30, 2018 were collected retrospectively. The patients were divided into low magnesium group (serum magnesium≤0.96 mmol/L), medium magnesium group (serum magnesium 0.97-1.07 mmol/L) and high magnesium group (serum magnesium≥1.08 mmol/L) according to the tertile of mean serum magnesium level. The differences of clinical data and laboratory results were compared among the three groups. Kaplan-Meier method was used to draw the survival curves, and log-rank test was used to compare the survival rate differences. Multivariate Cox regression was used to analyze the relationship between serum magnesium and all-cause mortality and cardiovascular and cerebrovascular diseases mortality in MHD patients. Results A total of 332 patients [194 males (58.4%)] were included in this study, with a median age of 63(51, 72) years and a median follow-up time of 36(20, 45) months. Kaplan-Meier survival analysis showed that the all-cause survival rate and cardiovascular and cerebrovascular diseases survival rate in the low magnesium group were lower than those in the medium magnesium group and the high magnesium group (Log-rank χ2=36.286, P＜0.001; Log-rank χ2=20.145, P＜0.001; respectively). After adjusting for multiple confounding factors, the results of multivariate Cox regression analysis suggested that low serum magnesium was an independent risk factor for all-cause death and cardiovascular and cerebrovascular diseases death in MHD patients. The risk of all-cause death and cardiovascular and cerebrovascular diseases death in the low magnesium group were significantly higher than those in the high magnesium group (HR=2.925, 95%CI 1.352-6.330, P=0.006; HR=3.821, 95% CI 1.394-10.473, P=0.009; respectively). Conclusions Hypomagnesemia may be an independent risk factor for all-cause death and cardiovascular and cerebrovascular diseases death in MHD patients. Low serum magnesium level increases the risk of all-cause death and cardiovascular and cerebrovascular diseases in MHD patients.     

Relationship between coronary artery calcification and outcomes in maintenance hemodialysis patients

Objective To evaluate the relationship between coronary artery calcification (CAC) and outcomes in maintenance hemodialysis (MHD) patients. Methods Eighty-six patients who were on MHD between October 2014 and May 2015 in the blood purification center of our hospital were enrolled prospectively. CAC was measured and scored by multiple slice computed tomography (MSCT). According to the CAC score (CACs), the patients were divided into mild CAC (CACs＜100) group and severe CAC (CACs≥100) group. Kaplan-Meier analysis was performed to analyze the survival rates of the two groups, and a COX proportional hazards regression model was used to estimate the risk factors of all-cause mortality and cardiovascular disease mortality in MHD patients. Results Severe CAC (CACs≥100) was present in 62.8% (54/86) patients. The median of follow-up duration was 28.9(23.8, 29.4) months. During the follow up, 2(6.3%) patients in CACs＜100 group and 18 (33.3%) patients in CACs≥100 group died. Kaplan-Meier survival analysis demonstrated that patients in CACs≥100 group had higher all-cause mortality and cardiovascular mortality as compared with patients in CACs＜100 group (P=0.007, P=0.030). Multivariate COX regression analysis demonstrated that CACs≥100 (HR=7.687, 95%CI 1.697-34.819, P=0.008) and low single-pool Kt/V (HR=0.092, 95%CI 0.020-0.421, P=0.002) were independent risk factors for all-cause mortality. Old age (HR=1.192, 95%CI 1.100-1.291, P＜0.001), short duration of dialysis (HR=0.598, 95%CI 0.445-0.804, P=0.001), low 25-hydroxy vitamin D3 (HR=0.461, 95%CI 0.326-0.630, P＜0.001), and low total cholesterol (HR=0.405, 95%CI 0.213-0.772, P=0.006) were independent risk factors for cardiovascular disease mortality. Conclusions The CACs is significantly related with overall survival in MHD patients. Large multicenter prospective studies are to be evaluated the association between CACs and long-term survival in MHD patients.     

维持性血液透析患者血清脂联素与动脉粥样硬化的相关性分析

目的探讨维持性血液透析患者血清脂联素水平与动脉粥样硬化的相关性。方法将30例维持性血液透析患者设为透析组,10名相匹配的健康体检者设为对照组,测定血清脂联素水平,同时测定相应的生化指标及颈总动脉内膜中层厚度,并根据颈动脉内膜厚度,将维持性血液透析患者分为颈动脉正常组和颈动脉硬化组。结果维持性血液透析患者血清脂联素水平明显高于对照组（P〈0．05）,与颈动脉内膜中层厚度呈显著负相关（r=－0．378,P〈0．05）;而颈动脉硬化组血清脂联素水平低于颈动脉正常组（P〈0．05）。结论维持性血液透析患者血清脂联素明显高于正常人,其浓度与动脉硬化程度呈负相关,对其更深一步的研究有助于对维持性血液透析患者动脉硬化的发生提供更好、更敏感的检测方法。     

终末期肾病患者心血管事件与血清胎球蛋白A及冠脉钙化的关系

目的探讨终末期肾病（ESRD）患者心血管事件发生与血清胎球蛋白A及冠脉钙化的关系。方法对38例ESRD初始血液透析患者进行血清胎球蛋白A及相关因素检测，对其中的29例患者进行冠状动脉多层螺旋CT钙化评价研究。所有38例患者随访时间为18个月。22例非ESRD慢性肾脏病（CKDⅡ～Ⅲ期）患者人选对照组。结果38例ESRD初始透析患者在18个月随访期内出现心血管事件30例次，因心血管事件死亡者6例，占15．79％，而非ESRD患者心血管事件仅3例次（P〈0．01）且无一例死亡（P〈0．05）。ESRD血清低胎球蛋白A组心血管事件显著高于ESRD血清高胎球蛋白A组（P〈0．01）。多元逐步回归分析显示，心血管事件与血清胎球蛋白A（P〈0．01）、C反应蛋白（CRP）（P=0．0014）及低密度脂蛋白C（LDL-C）（P=0．008）密切相关。18／29例（62．07％）有冠状动脉钙化。冠状动脉钙化患者心血管事件比无冠状动脉钙化患者显著增多（P〈0．01）。冠脉钙化的ESRD患者血清胎球蛋白A水平较无冠脉钙化的ESRD患者明显下降（P〈0．01）。冠脉钙化与胎球蛋白A下降及高血磷有关（P〈0．01，P〈0．01）。结论ESRD透析患者心血管事件和（或）心血管事件死亡可能与血清胎球蛋白A下降及冠状动脉钙化有关。     

Association of serum magnesium level with all-cause mortality in maintenance hemodialysis patients

Objective To investigate the association of serum magnesium (Mg) level with all-cause mortality in maintenance hemodialysis patients. Methods A multicenter retrospective cohort study was conducted in seven hemodialysis centers of Guizhou province. The adult outpatients who underwent hemodialysis for more than 3 months were included from June 2015 to June 2016. Demographics, baseline clinical and laboratory test results were collected. All patients were followed up until June 30, 2018. Patients were divided into 4 groups according to their baseline serum Mg levels (interquartile range). Kaplan-Meier method was used to compare the survival rates of the four group. Cox regression model was used to analyze the association of Mg with all-cause mortality. Logistic regression was used to analyze the influencing factors of low Mg level. Results A total of 868 hemodialysis dialysis patients with baseline Mg data were enrolled in this study, with age of (55.47±16.17) years old, among whom 59.4% were male. There were 11 (1.3%) patients with hypomagnesemia (Mg＜0.7 mmol/L), 432(49.8%) patients with hypermagnesemia (Mg＞1.05 mmol/L), and 16(1.8%) patients with Mg＞2.0 mmol/L. Median Mg was 1.05 mmol/L and interquartile range was 0.95-1.24 mmol/L. The comparison between Mg quartile groups showed that the difference in age, hemoglobin, serum albumin, serum calcium, parathyroid hormone (PTH), serum creatinine, uric acid and urea nitrogen was statistically significant (all P＜0.05). After a median follow-up of 24 months, 207 patients died. Kaplan-Meier curves showed higher all-cause mortality in patients with Mg≤0.95 mmol/L (Q1 group) (Log-rank test χ2=15.11, P=0.002). However, after adjusting for age, comorbidities and biochemical indicators(especially albumin), there was no statistically significant difference in the hazard ratio for all-cause death among the four groups. Multiple logistic regression analysis results showed that low serum albumin (OR=0.946, 95%CI 0.913-0.979, P=0.002) and low serum uric acid (OR=0.994, 95%CI 0.992-0.997, P＜0.001) were the risk factors for baseline Mg≤0.95 mmol/L. Conclusions Hypomagnesemia is rare in MHD patients, while hypermagnesemia is more common. Baseline serum Mg≤0.95 mmol/L in MHD patients is correlated with increased risk of all-cause death, but it may be not an independent risk factor. Baseline serum Mg≤0.95 mmol/L that occurred is associated with low levels of albumin and serum uric acid.     

Association between serum soluble Klotho level and outcome in patients on maintenance hemodialysis

Objective To determine the relationship between serum soluble Klotho (sKL) level and adverse outcome in maintenance hemodialysis (MHD) patients. Methods One hundred and twenty nine cases of MHD patients were collected prospectively. Serum sKL was detected by ELISA. Abdomen lateral plain was used as a criterion to determine the abdominal aortic calcification. The abdominal aortic calcification score (AAC) was calculated. Cox regression analysis was used to determine the risk factor of cardiovascular death (CVD) in MHD patients. Kaplan-Meier showed the relationship between sKL and CVD in MHD patients. Results There were 27 cases (20.9%) of all-cause death and 19 cases (14.7%) of cardiovascular death. The median sKL was 612.6(379.2-816.6) ng/L, and log[iPTH] was an independent factor of sKL concentration. Low sKL had high AAC and CVD death rate. Kaplan-Meier method showed that the all-cause death rate was similar between two groups, and CVD death rate increased significantly in low sKL patients (P=0.036). Cox regression indicated that lower sKL level was associated with high CVD death rate [OR=0.352, 95%CI(0.127- 0.977), P=0.045].After adjustment for the general condition, biochemical indicators, the relationship still existed [OR=0.331, 95% CI (0.117-0.933), P=0.037]. In no or mild vascular calcification patients (AAC≤4), compared with high sKL patients, low sKL patients had no significant difference rate in all-cause mortality. The CVD mortality was significantly higher in high sKL (P=0.035) compared with low sKL. In severe calcification group (AAC＞4),all-cause death and CVD death rates were similar between different sKL groups (P=0.991 and 0.522, respectively). Conclusions Lower sKL has the high CVD death rate and sKL level decreasing is an independent risk factor for CVD death in MHD patients. The lower sKL concentration in MHD patients with no or mild calcification may predict CVD mortality. This study suggests that sKL levels may be helpful in predicting the outcome of patients with MHD.     

Measurement of coronary artery calcification with multi-slice spiral computed tomography and the associated factors in maintenance hemodialysis patients

Objective To investigate the factors correlated to coronary artery calcification (CAC) in maintenance hemodialysis (MHD) patients. Methods This study included 132 patients(54 females, 78 males), aged 26-94 years, who were on hemodialysis for 10-204 months(median dialysis duration 51.00 months). The parameters including calcium, phosphorus, parathyroid hormone, total cholesterol, low density lipoprotein, triglycerides, C - reactive protein (CRP), klotho, and so on were assessed. Quantification of CAC was determined by multi-slice spiral computed tomography (MSCT), known as the coronary artery calcification score (CACs). Results Ninety-two patients (69.70%) had CAC, with CACs ranging from 0 to 13 450.20. More than 30% patients experienced one even a variety of cardiovascular and cerebrovascular diseases. A positive correlation was observed between the degree of CAC and the incidence of cardiovascular and cerebrovascular diseases. Whereas a positive correlation existed between CACs and age (r=0.347, P=0.000), duration of hemodialysis (r=0.245, P= 0.005), systolic blood pressure (r=0.184, P=0.034), diabetes history (r=0.211, P=0.015), phosphorus (r= 0.262, P=0.002), calcium-phosphorus product (r=0.247, P=0.004); and a negative correlation between CACs and klotho level (r=-0.294, P=0.001). Multivariate logistic regression analysis showed that the main factor influencing the degree of CAC in MHD patients was age. Conclusions CAC is common and widespread in hemodialysis patients, who are often accompanied by cardiovascular and cerebrovascular diseases. The prevalence rate of cardiovascular and cerebrovascular diseases increases with the aggravation of CAC degree. Age, duration of hemodialysis, systolic blood pressure, diabetes history, disturbance of calcium and phosphorus metabolism and klotho are correlated with the severity of CAC. Age is an independent risk factor of CAC degree.     

Relationship between ultrafiltration rate and cardiovascular death in maintenance hemodialysis patients

Objective To investigate the relationship between ultrafiltration rate (UFR) and cardiovascular death in maintenance hemodialysis patients. Methods This retrospective study observed adult hemodialysis patients treated in Kidney Disease Center, the First Affiliated Hospital, College of Medicine, Zhejiang University during January 2010 to December 2015 and the follow-up were finished at April 2017. Patients were averagely divided into 3 groups according to their UFR. Their clinic characteristics were collected, the survival rate and death related factors were analyzed by Kaplan-Meier (Log-rank test) method and Logistic regression. Results Totally 2184 patients (male 1370, 62.7%) were enrolled, the age was 53.39±16.47. The UFR was (8.88±3.05) ml?h-1?kg-1. During the 7 years' follow-up, 168 patients died, of whom 58 cases (34.5%) died due to the cardiovascular events. Chi-square test showed that there were significant differences in death causes among the high, middle and low UFR group (χ2=12.584, P＜0.01), and the mortality rate of cardiovascular events in high UFR group was significantly higher than that in low (χ2=10.861, P= 0.010) and middle UFR group ( χ2=4.671, P=0.031). Kaplan-Meier survival curve showed that the difference of the survival rates in the 3 groups was statistically significant (Log-rank test χ2=23.394, P＜0.001). Cox regression analysis showed that high UFR (UFR≥10.95 ml?h-1?kg-1), old age (＞60 years old), and low left ventricular ejection fraction (LVEF, ≤50%) were independent risk factors of cardiovascular death. Conclusions High UFR level, old age and low LVEF are independent risk factors of cardiovascular death in hemodialysis patients. Maintaining low UFR level is beneficial to reduce cardiovascular mortality in hemodialysis patients.     

血清铁调素25水平与腹膜透析患者冠状动脉钙化及心血管事件的关系

目的 探讨持续性腹膜透析患者血清铁调素25（hepcidin-25）水平和冠状动脉钙化（coronary artery calcification,CAC）及心血管事件的关系.方法 选择210例持续性非卧床腹膜透析（continuous ambulatory peritoneal dialysis,CAPD）患者血清hepcidin-25的平均值为界,分为CAPD高hepcidin-25组107例、CAPD低hepcidin-25组103例;另选择在本院进行健康体检者90名作为健康对照组.通过酶联免疫法（enzyme-linked immunosorbent assay,ELISA）测定所有CAPD患者和健康对照组血清hepcidin-25水平.对所有入选者进行冠状动脉多层螺旋电子计算机断层扫描成像（multi-slice computed tomography,MSCT）钙化评价研究.结果 CAPD高hepcidin-25组在随访12个月内发生心血管事件71例次,因心血管事件死亡21例（占19.6%）;而CAPD低hepcidin-25组发生心血管事件27例次,因心血管事件死亡仅10例（占9.7%）.CAPD高hepcidin-25组和CAPD低hepcidin-25组心血管事件发生率比较,差异有统计学意义（P＜0.01）,以上2组无心血管事件生存率无统计学差异（P=0.055）.CAPD患者心血管事件发病率[46.7%（98/210）]与健康对照组心血管事件发病率[5.6%（5/90）]比较,差异有统计学意义（P＜0.01）.CAPD高hepcidin-25组CAC发病率均明显高于CAPD低hepcidin-25组（P＜0.01）;而且相关性分析显示,hepcidin-25水平与CAC积分呈正相关（r=0.980,P＜0.01）.多元逐步回归分析显示血清hepcidin-25水平[偏回归系数（B）=0.402,P＜0.01]和CAC（B=-0.015,P＜0.01）是CAPD患者心血管事件发生的重要危险因素.结论 血清hepcidin-25水平升高及CAC是CAPD患者发生心血管事件的重要原因,提示铁代谢紊乱可能参与,且促进了CAC的发生、发展,并最终导致心血管事件的发生.     

Relationship between abdominal aortic calcification and outcomes in maintenance hemodialysis patients

Objective To investigate the relationship between abdominal aortic calcification (AAC) and outcomes in maintenance hemodialysis (MHD) patients. Methods One hundred and seventy MHD patients in the dialysis center of the Second Hospital of Tianjin Medical University from June 2014 and October 2014 were enrolled prospectively. Abdominal aortic calcification (AAC) was measured using AAC score (AACS) by abdominal lateral plain radiography. According to the AACS, the patients were divided into mild AAC (AACS＜5) group and severe AAC (AACS≥5) group for comparison, and Kaplan-Meier analysis was used to compare their survival rates. Multivariable COX regression models were used to determine the risk factors of all - cause mortality and cardiovascular disease mortality in MHD patients. Results Severe AAC (AACS≥5) was present in 28.2% (48/170) patients. The median follow-up duration was 25.6 (22.0, 26.0) months. During the follow-up, 6 patients (4.9%) in AACS＜5 group and 14 patients (29.2%) in AACS≥5 group died. Kaplan-Meier analysis showed that patients in AACS≥5 group had higher all-cause mortality rate and cardiovascular disease mortality rate as compared with patients in AACS＜5 group (χ2=9.746,P=0.002; χ2=9.697,P=0.002). Multivariate COX regression analysis demonstrated that high AACS (HR=4.373, 95%CI 1.562-7.246, P=0.005) and hypoproteinemia (HR=0.886, 95% CI 0.797 - 0.985, P=0.025) were independent risk factors for all-cause mortality, while hypoproteinemia (HR=0.829, 95%CI 0.718-0.956, P=0.010) and low 1,25(OH)D3 (HR=0.769, 95% CI 0.627 - 0.944, P=0.012) were independent risk factors for cardiovascular disease mortality. Conclusions AAC is significantly associated with overall survival in MHD patients. To further evaluate the relationship between AAC and outcomes in MHD patients, multi-center and long term follow up studies of large sample size are necessary.     

Assessment of frailty and its influence factors in maintenance hemodialysis patients

Objective To investigate the frailty in maintenance hemodialysis (MHD) patients and its influence factors. Methods A total of 127 adults undergoing hemodialysis from January 2015 and January 2016 in our center were recruited. Their clinical data and blood biochemical data were collected. Frailty was assessed using Fried's Frailty Phenotype. Quantification of coronary artery calcification (CACs) was determined by multi-slice spiral computed tomography (MSCT). According to the frailty scores, patients were divided into non-frailty, pro-frailty and frailty group. Their in clinical and biochemical index as well as CACs were compared. The correlations of frailty scores with above index were assessed by Spearman's correlation. Multiple logistic regression analysis was applied to evaluate the effect factors of frailty on MHD patients. Results Among 127 selected patients, 46(36.22%) patients without frailty, 45(35.43%) patients with pro-frailty, and 36(28.35%) patients with frailty. The age, diabetes, haemoglobin, albumin, pre-albumin, C-reactive protein, fibroblast growth factor 23 (FGF23), CACs and left ventricular end-diastolic dimension (LVEDD) of the 3 groups had statistical differences (all P＜0.05). The degrees of calcification among 3 groups were also different statistically (F=31.769, P＜0.001). In patients with MHD, frailty was positively correlated with age (r=0.545, P＜0.001), diabetes (r=0.236, P=0.008), C-reactive protein (r=0.245, P=0.006), FGF23 (r=0.189, P=0.034) and CACs (r=0.396, P＜0.001), while negatively correlated with haemoglobin (r=-0.257, P=0.004), albumin (r=-0.380, P＜0.001), pre-albumin (r=-0.313, P＜0.001). Age (OR=1.076), C-reactive protein (OR=1.176), albumin (OR=0.796) and artery calcification (OR=2.465) were independent influence factors for frailty in MHD patients (all P＜0.05). Conclusions The prevalence of frailty is high among MHD patients. Frailty is associated with age, C-reactive protein, albumin and artery calcification in MHD patients.     

Relationship between endothelial progenitor cells and cardiovascular diseases in maintenance hemodialysis patients

Objective To investigate the relationship between the variation of endothelial progenitor cells (EPC) number and cardiovascular diseases (CVD) in maintenance hemodialysis (MHD) patients,and discuss the function of EPC in the progression of CVD in MHD. Methods One hundred and fifteen MHD patients over 18 years whose dialysis vintage was over six months from Department of Nephrology, Renji Hospital, Shanghai Jiao Tong University School of Medicine were enrolled. They were divided into CVD group and non - CVD group by medical history, electrokardiographie (EKG), cardiac ultrasound, peripheral vascular imaging and cardiovascular imaging. Peripheral blood (5 ml) was collected for detecting EPC number by flow cytometry as CD34/CD133/vascular endothelial growth factor receptor 2 (VEGFR2) cells. The EPC number between CVD group and non-CVD group was compared. The relationship between the decrease of EPC number and CVD risks in MHD patients was analyzed by logistic regression analysis. In a three-year follow-up, the death and new CVD events of the two groups were compared in order to discuss the relationship between EPC number and adverse events. Results Among 115 MHD patients, the average age was 61.57 ± 12.76, male/female was 71/44, the average dialysis vintage was (86.24 ± 56.31) months, the average Kt/V was 1.69±0.29 and average ultrafiltration volume was (2.48±0.90) L. Forty-four patients in 115 (38.3%) were with concurrent CVD. The EPC number in CVD group was significantly lower than that in non CVD group (P=0.015). The CVD group had higher serum phosphate (P=0.013), higher glycosylated hemoglobin (P＜0.001), but serum calcium, intact parathyroid hormone (iPTH) and other indicators had no significant difference between two groups. Multiple Logistic regression analysis showed that older age (OR=1.061), history of diabetes (OR=9.796), dialysis vintage (OR=1.015), serum phosphate (OR=3.766), decrease of EPC number (OR=0.909) were the independent impact factors of CVD events in MHD patients. There were 22 patients of the 115 MHD patients had encountered a new CVD event in a three-year follow-up between December 2012 and December 2015, 9 patients from the CVD group and 13 patients from the Non-CVD group, and there was no significant difference between two groups (P=0.776). Nine patients from the CVD group and 7 patients from the Non-CVD group died in the follow-up, and there was no significant difference (P=0.111). Seventy-one MHD patients from the non-CVD group were divided into two groups by the median of EPC number. There were 3 patients in the higher EPC number group encountered CVD events and 10 patients in the lower EPC number group encountered CVD events, which had significant difference (P=0.024). Conclusion The decrease of circulating EPC number may be related with CVD events in MHD patients. Even adjusted by age, sex, diabetes, dialysis vintage and serum phosphate, decreased EPC number is still the independent risk factor of CVD events in MHD patients. The decrease of EPC number in MHD patients may be used to predict the occurrence of cardiovascular events.     

维持性血液透析患者冠心病介入治疗

目的探讨维持性血液透析患者合并冠心病心脏介入治疗的安全性和可行性。方法回顾性分析本院7例血液透析合并冠心病患者在强化透析的基础上应用非离子型低渗造影剂行冠状动脉造影术＋支架植入术的临床资料。结果单支病变3例,多支病变4例,行经皮腔内冠状动脉成形术（PTCA）置放支架1～2个。死亡3例,病情改善4例。此4例术后心绞痛症状改善,肾功能无进一步恶化。结论血液透析患者中合并不稳定心绞痛患者可考虑冠状动脉介入治疗,疗效较好,但对于同时有心肌酶谱升高者预后不良。     

氟伐他汀对维持性血液透析患者氧化应激及非对称性二甲基精氨酸的影响

目的观察口服氟伐他汀对维持性血液透析（MHD）患者氧化应激状态和非对称二甲基精氨酸（asymmetric dimethylarginine,ADMA）及颈动脉粥样硬化斑块的影响。方法选择透析时间超过6个月的MHD患者64例,分为治疗组36例和对照组28例,治疗组口服氟伐他汀（40mg,1次／d）治疗;对照组不用氟伐他汀。进行为期6个月随访,分别检测治疗前、治疗后6个月末患者的ADMA、血总胆固醇（TC）、三酰甘油（TG）、高密度脂蛋白胆固醇（HDL-C）、低密度脂蛋白胆固醇（LDL-C）、超敏C反应蛋白（hs-CRP）、白细胞介素6（IL-6）、肿瘤坏死因子α（TNF-α）、丙二醛（MDA）。结果治疗后6个月末,2组HDL-C均较治疗前明显升高（P〈0．05）,TC、TG、LDL-C较治疗前明显降低（P〈0．05）,且CRP、IL-6、TNF-α、MDA和ADMA较治疗前明显降低（P〈0．05）。结论氟伐他汀可明显改善MHD患者的血脂水平,同时可改善患者氧化应激状态和降低ADMA的水平。     

血液透析患者动脉弹性功能及相关因素分析

目的探讨维持性血液透析（MHD）患者在血液透析前、后脉搏波速度（PWV）和压力反射波增强指数（AIx）水平变化及其相关因素。方法选择92例MHD患者,采用标准袖带水银血压计测量非动脉一静脉内瘘侧上臂坐位血压,动脉脉搏波分析仪检测动脉弹性指数AIx和PwV,并分别与各因素进行单因素相关分析和多元逐步回归分析。结果血液透析患者的袖带血压、中心动脉压、PWV和AIx在血液透析前后均无显著性变化（P〉0．05）;多元逐步回归分析表明,AIx与患者的年龄、性别、主动脉收缩压有明显相关（P〈0．05）,而PWV与患者年龄、上臂舒张压、钙磷乘积、身高、透析时间和心率存在明显相关（P〈0．05）;PWV与AIx之间有明显相关（P〈0．05）。结论（1）血液透析患者的AIx与PWV、中心动脉压收缩压（C_SP）、身高、血清白蛋白、性别和年龄存在相关关系,其中与PWV、性别、年龄和C_SP呈正相关;而与身高和血清白蛋白呈负相关。（2）血液透析患者的PWV与AIx、年龄、舒张压、钙磷乘积、身高、透析时间和心率存在相关关系,其中与AIx、年龄、钙磷乘积、舒张压、透析时间及心率呈正相关,仅与身高呈负相关。     

Effect of serum uric acid level on prognosis in maintenance hemodialysis patients

Objective To analyze the relationship between serum uric acid (SUA) level and clinical indicators in maintenance hemodialysis (MHD) patients, and explore its influence on all-cause mortality and cardiovascular mortality. Methods This study was a retrospective cohort study. Patients who received MHD from the blood purification center of the Third Affiliated Hospital of Sun Yat-sen University from January 1, 2011 to December 30, 2015 were enrolled in the queue. They were divided into 3 groups according to the first and third quantile of the SUA level quartiles, and the baseline data of clinical and laboratory examinations were compared. The correlation between SUA level and clinical indicators was analyzed by Pearson correlation coefficient. Kaplan-Meier method and Cox proportional hazard regression model were used to examine the association between SUA and all-cause mortality and cardiovascular mortality in MHD patients. Results A total of 201 patients were enrolled in the study. The age of the patients was (56.9±16.7) years and the baseline SUA level was (531.1±137.9) μmol/L. Patients were divided into 3 groups with the first quantile (442 μmol/L) and the third quantile (620 μmol/L) of the SUA quartiles as the boundary points: group 1 (SUA＜442 μmol/L, n=52), group 2 (SUA 442-620 μmol/L, n=101) and group 3 (SUA＞620 μmol/L, n=48). The results showed that the patients in group 1 were older and had more proportion of patients with diabetes mellitus and cardiovascular diseases than those in group 3 (all P＜0.05). Compared to group 3, the serum albumin, serum phosphorus and serum creatinine were lower in group 1, while the hypersensitive C-reactive protein was higher (all P＜0.05). Pearson correlation analysis showed that SUA level was positively correlated with albumin (r=0.135, P=0.047), blood phosphorus (r=0.269, P＜0.001) and serum creatinine (r=0.333, P＜0.001), and negatively correlated with hypersensitive C-reactive protein (r=-0.216, P=0.002). After a median follow-up of 49.8 months, 66(32.8%) all-cause deaths and 32(15.9%) cardiovascular deaths were recorded. Kaplan-Meier method showed that with the decrease of SUA, all-cause mortality (Log-rank χ2=18.27, P＜0.001) and cardiovascular mortality (Log-rank χ2=15.04, P=0.001) increased. After adjusting for age, gender, comorbidity and other factors using the Cox proportional hazards model, the all-cause mortality and cardiovascular mortality decreased by 20.1% (HR=0.799, 95% CI 0.651-0.980, P=0.031) and 29.6% (HR=0.704, 95% CI 0.524-0.946, P=0.020) for each 100 μmol/L increase in baseline SUA. Compared to group 1, all-cause mortality (HR=0.332, 95%CI 0.142-0.774, P=0.011) and cardiovascular mortality (HR=0.140, 95%CI 0.030-0.657, P=0.013) were lower in the group 3. Conclusion Low SUA level increases the risk of all-cause mortality and cardiovascular mortality in MHD patients.     

Association of serum FGF23 with abdominal aortic calcification and outcomes in maintenance hemodialysis patients

Objective To explore the association of fibroblast growth factor-23 (FGF23) with abdominal aortic calcification(AAC) and adverse outcomes in maintenance hemodialysis patients. Methods One hundred and fourteen cases of MHD patients were collected prospectively. Serum intact FGF23 was detected by ELISA. Abdomen lateral plain was used as a criteria to determine the abdominal aortic calcification and the abdominal aortic calcification score was counted. Logistic regression analysis was used to determine the risk factors of AAC. Kaplan-Meier analysis was applied to compare the survival rate among different groups and COX regression analysis was used to determine the association of FGF23 and mortality in MHD patients. Results Seventy-six patients present abdominal aortic calcification. The median of AACS was 4.0(0.0, 11.0). The median level of FGF23 was 7277.4(2535.0, 9990.8) pg/ml. The median follow-up duration was 72.0(67.8, 72.8) months. During the follow-up, 22 patients (19.3%) died of all-cause death and 17 cases (14.9%) died of cardiovascular diseases. Serum FGF23 level was positively correlated with AAC (r=0.285, P=0.002). Logistic regression analysis showed that longer age (OR=1.059, 95%CI: 1.020-1.100, P=0.003) and dialysis vintage (OR=1.009, 95%CI 1.000-1.017, P=0.039), smoking history (OR=3.010, 95%CI 1.177-7.696, P=0.021) and higher FGF23 level(OR=2.831, 95%CI 1.010-7.937, P=0.048) were independent risk factors of moderate to severe AAC in MHD patients. Kaplan-Meier survival curves showed that the patients with AACS≥5 had significantly higher all-cause mortality(P=0.028) and CVD mortality (P=0.035) than those with AACS＜5. However, the Kaplan-Meier analysis showed no significant difference regarding the level of serum FGF23 with the all-cause and CVD mortality. Cox regression demonstrated that FGF23 was not associated with increased mortality risk, neither in crude nor in multivariate adjusted models. Conclusions Abdominal aortic calcification had a high prevalence in MHD patients. The all-cause and CVD mortality was higher in patients with moderate to severe AAC. FGF23 was an independent risk factor of moderate to severe AAC, but it can't yet be a predictor for the all-cause and CVD mortality of MHD patients.     

Relationship between T-helper cell 17/regulatory T cell imbalance and atherosclerosis cardiovascular disease in maintenance hemodialysis patients

Objective To investigate whether the T-helper cell 17 (Th17)/regulatory T cell (Treg) of patients on maintenance hemodialysis (MHD) present imbalance in terms of proportion and function, and if so, the relationship between such imbalance and atherosclerosis cardiovascular disease (ASCVD). Methods Fifty-seven MHD patients, included 25 with ASCVD and 32 without ASCVD, and 24 healthy volunteers were enrolled. The common carotid artery intima media thickness (CCA-IMT), carotid plaque and plaque area were determined with high-resolution B-mode ultrasonography. Treg (CD4+CD25+Foxp3+) and Th17 (CD4+IL-17+) were measured by flow cytometry. The Foxp3 and RAR-related orphan receptor γt (RORγt) mRNA expressions were measured by real-time PCR. TGF-β1, IL-10, IL-17 and IL-6 in serum were detected by ELISA. Results There were decreased Treg proportion, Foxp3 mRNA, TGF-β1 and IL-10, and increased Th17 proportion, RORγt mRNA, IL-17, IL-6 and Th17/Treg in the ASCVD group compared with that in the non-ASCVD group and healthy group (all P＜0.01). No correlation was observed between Treg and CCA-IMT, but IL-10 were negatively correlated with CCA-IMT (P＜0.05). Th17, IL-17 and ratio of Th17/Treg were positively correlated with CCA-IMT (all P＜0.05). MHD patients with carotid plaques had lower Treg, TGF-β1 and IL-10, higher Th17, IL-17 and ratio of Th17/Treg than those without carotid plaques (all P＜0.05). Moreover, Treg proportion was negatively correlated with carotid plaque area in MHD patients with carotid plaques (P＜0.01). Conclusions The Th17/Treg numerical and functional imbalance exists in MHD patients, especially in patients with ASCVD. This might act synergistically with micro-inflammation on immune-mediated atherosclerosis and contribute to the high incidence of ASCVD.     

糖尿病与非糖尿病维持性血液透析患者血管钙化的对比研究

目的探讨糖尿病维持性血液透析（MHD）患者血管钙化的影响因素。方法选择我院MHD患者90例,其中糖尿病组21例、非糖尿病组69例。检测2组透析前、后血压、心率、相关血生化指标以及全段甲状旁腺素（iPTH）、1,84-PTH、25一羟一维生素功,比较2组血管钙化情况,探讨糖尿病组患者血管钙化的相关因素。结果与非糖尿病组相比,糖尿病组透析前血肌酐较低,三酰甘油较高,高密度脂蛋白胆固醇较低（P〈0．05）。糖尿病组iPTH达标率高于非糖尿病组,而钙磷乘积低于后者（P〈0．05）。糖尿病组钙化发生率和钙化积分高于非糖尿病组（P〈0．05）。对糖尿病MHD患者,血管钙化积分与糖尿病病程、慢性肾脏病（CKD）病程、透析时间、iPTH、碱性磷酸酶呈正相关（r值分别为0．491、0499、0．652、0．727和0．564,P值均〈0．05）。结论与非糖尿病患者相比,患有糖尿病的MHD患者有较高的血管钙化发生率及较重的血管钙化程度;其中糖尿病病程、CKD病程、透析时间、iPTH、ALP可能参与糖尿病患者血管钙化的发生和发展。     

Prognostic value of red cell distribution width in maintenance hemodialysis patients

Objective To investigate the relationship of red cell distribution width (RDW) with all-cause mortality and cardiovascular disease (CVD) mortality in patients undergoing maintenance hemodialysis (MHD). Methods A retrospective analysis was performed in patients who initiated MHD from January 2008 to September 2017 in the hemodialysis center of the Second Affiliated Hospital of Soochow University. Basic data on demographic, dialysis and laboratory were collected, and echocardiography indicators and clinical outcomes were recorded. Patients were divided into four groups according to the quartile of RDW level. Kaplan-Meier survival analysis was used to compare the difference of survival rate among the groups. Cox regression analysis was used to analyze the risk factors of all-cause and CVD-related mortality, and predictive value of RDW for all-cause and CVD-related death in hemodialysis patients. Results A total of 268 MHD patients were enrolled in this study with age of (60.9±15.8) years and dialysis duration of (58.1±9.1) months, including 159 males(59.3%). Kaplan-Meier survival analysis showed that the 1-year overall survival rates of Q1 group (RDW≤13.8%, n=61), Q2 group (RDW 13.9%-14.6%, n=66), Q3 group (RDW 14.7%-15.6%, n=73) and Q4 group (RDW≥15.7%, n=68) were 96.8%, 95.1%, 93.1% and 85.7% respectively; 3-year overall survival rates were 88.5%, 87.5%, 59.2% and 51.8% respectively; 5-year overall survival rates were 71.5%, 65.4%, 33.6% and 17.7% respectively; The difference between the groups was statistically significant (all P＜0.01). The 1-year CVD survival rates were 98.4%, 96.6%, 95.8% and 92.4% respectively; 3-year CVD survival rates were 94.8%, 92.5%, 84.4% and 70.4% respectively; 5-year CVD survival rates were 86.9%, 81.3%, 65.6% and 51.3% respectively; The difference between the groups was statistically significant (all P＜0.01). Multivariate Cox regression analysis showed that RDW≥15.7% was an independent risk factor for all-cause and CVD-related mortality in MHD patients. The risk of all-cause mortality in Q4 group was 3.098 times higher than that in Q1 group (95%CI 1.072-8.950, P=0.037) and the risk of CVD-related mortality was 2.661 times (95%CI 1.111-8.342, P=0.048). Receiver operating characteristic curve (ROC) showed that RDW=14.85% was the best cut-off point for predicting the all-cause mortality in HD patients (P＜0.01), RDW=15.45% was the best cut-off point for predicting the cardiovascular disease mortality (P＜0.01), and RDW=14.45% had a higher 5-year survival rate (P＜0.01). Conclusion RDW can independently predict all-cause and CVD-related mortality risk in hemodialysis patients, and it has important value for prognosis.