红细胞分布宽度预测维持性血液透析患者预后的价值

目的探讨红细胞分布宽度(RDW)预测维持性血液透析(MHD)患者全因死亡及心血管疾病(CVD)死亡的价值。方法回顾性分析苏州大学附属第二医院2008年1月至2017年9月登记管理的268例MHD患者的人口学资料、透析数据、实验室指标、心脏超声检查指标及临床结局。按照RDW水平四分位数进行分组。使用Kaplan-Meier生存曲线比较各组患者总生存率和心血管疾病生存率的差异;Cox回归分析法分析MHD患者全因死亡及心血管疾病死亡的危险因素,及RDW预测MHD患者全因死亡和心血管疾病死亡的价值。结果本研究共纳入268例MHD患者,年龄(60.9±15.8)岁,透析龄(58.1±9.1)个月,其中男性159例(59.3%)。Kaplan-Meier生存分析结果显示,Q1组(RDW≤13.8%,n=61)、Q2组(RDW 13.9%~14.6%,n=66)、Q3组(RDW 14.7%~15.6%,n=73)、Q4组(RDW≥15.7%,n=68)患者1年总生存率分别为96.8%、95.1%、93.1%和85.7%;3年总生存率分别为88.5%、87.5%、59.2%和51.8%;5年总生存率分别为71.5%、65.4%、33.6%和17.7%,组间比较差异均有统计学意义(均P<0.01)。4组患者1年心血管疾病生存率分别为98.4%、96.6%、95.8%和92.4%;3年心血管疾病生存率分别为94.8%、92.5%、84.4%和70.4%;5年心血管疾病生存率分别为86.9%、81.3%、65.6%和51.3%,组间比较差异均有统计学意义(均P<0.01)。校正多项混杂干扰因素后,多因素Cox回归分析结果提示,RDW≥15.7%是MHD患者全因死亡及心血管疾病死亡的独立危险因素,Q4组患者的全因死亡风险及心血管疾病死亡风险分别为Q1组的3.098倍(95%CI 1.072~8.950,P=0.037)及2.661倍(95% CI 1.111~8.342,P=0.048)。受试者工作特征曲线(ROC)结果显示,RDW=14.85%是预测MHD患者全因死亡的最佳截点(P<0.01),RDW=15.45%是预测心血管疾病死亡的最佳截点(P<0.01),RDW=14.45%的MHD患者5年生存率较高(P<0.01)。结论RDW可独立于其他因素预测MHD患者全因死亡及心血管疾病的死亡风险,对预后的判断具有重要价值。

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.