维持性血液透析患者微炎症状态的临床研究

目的 探讨维持性血液透析(maintenance hemodialysis,MHD)患者微炎症状态及其影响因素.方法 检测中国医科大学附属第一医院血液净化中心MHD的慢性肾衰竭患者51例作为MHD组,搜集这些患者的临床资料:29例健康体检者作为对照组.检测血清C反应蛋自(C-reactive protein,CRP),血清白细胞介素6(interleukin-6,IL-6),肿瘤坏死因子a(tumor necrosis factor-a,TNF-α),与对照组LL较:检测MHD组血清肌配(serum creatinine,SCr)、血尿素氮(blood urea nitrogen,BUN)、血红蛋白(hemoglobin,Hb)、转铁蛋白(transferrin,TRF)、血清白蛋白(albumin,Alb),碳酸氢根离子(HCO_3)等相关指标,并进行相关性分析.根据MHD组患者有无服用血管紧张素转换酶抑制剂(angiotensin con-verting enzyme inhibitor,ACEI)/血管紧张Ⅱ素受体拮抗剂(angiotensin Ⅱ receptor blocker,ARB)药物,将MHD组分为ACEI/ARB服用组和未服用组,比较2组之间CRP、IL-6,TNF-α之间有无差异.结果 MHD组与对照组比较,血CRP升高,分别为(8.88±8.46) mg/L和(0.80±0.20) mg/L;IL-6升高,分别为(10.57±5.25)pg/ml和(1.70±0.43)pg/ml;TNF-α升高,分别为(30.55±12.84)pg/ml和(11.36±3.14)pg/ml,差异均有统计学意义(均P<0.01).相关性分析表明,MHD组患者CRP与IL-6,TNF-α,BUN,SCr、透析龄呈现著正相关(r=0.526,P<0.01;r=0.511,P< 0.01;r=0.279,P<0.05;r=0.287,P<0.05;r-0.298,P<0.05),与Alb,TRF,HCO,呈明显负相关(r=0.573,P<0.05;r＝-0.46,P<0.01;r=0.479,P<0.01),与Hb,患者年龄无显著相关性.ACEI/ARB服用组与未服用组比较,血CRP降低,分别为(0.55±0.32) mg/L和(10.07±9.34)mg/L;IL-6降低,分别为(9.66±4.53)pg/ml和(14.24±6.69)pg/ml;TNF-α降低,分别为(26.36±11.25)pg/ml和(38.35±16.46)pg/ml,差异均有统计学意义(均P< 0.05).结论 MHD患者存在微炎症状态,作为描述MHD患者微炎症状态比较好的生化指标CRP,与患者透析龄、血HCO,有一定的相关性.微炎症状态对MHD患者营养状况有重要影响.ACEI/ARB药物能改善MHD患者微炎症状态.

Clinical study on micro-inflammatory state in maintenance hemodialysis patients

Objective To investigate the micro-inflammatory state and its related factors in maintenance hemodialysis （MHD） patients. Methods We recruited 51 MHD patients with chronic renal failure （MHD group）, and 29 healthy volunteers （control group）. Their micro-inflammation indicators, including serum C-reactive protein （CRP）, interleukin-6 （IL-6） and tumor necrosis factor-＇（TNF-＇, were assayed and compared between the 2 groups. Serum creatinine （Scr）, blood urea nitrogen （BUN）, hemoglobin （Hb）, transferrin （TRF）, serum albumin （ALB）, bicarbonate ions （HCO3-）, serum parathyroid hormone （PTH） and other related indicators were also determined in MHD group, and correlation analyses were made among biochemical parameters. We subdivided the patients in MHD group into ACEI/ARB（＋） group and ACEI/ARB（-） group based on whether angiotensin-converting enzyme inhibitor II/angiotensin II receptor 1 blockers （ACEI/ARB） were used in these patients. We then compared CRP, IL-6 and TNF-＇between the 2 subgroups. Results （a） When comparisons were made between MHD group and control group, serum CRP[ （8.88±8.46）mg/L vs. （0.8±0.2）mg/L, P0.01], IL-6 [（10.57±5.25）pg/ml vs. （1.70±0.43）pg/ml, P0.01] and TNF-＇[（30.55±12.84）pg/ml vs. （11.36±3.14）pg/ml, P0.01] were significantly increased in MHD group. （b） Correlation analyses within MHD group disclosed that serum CRP positively correlated with IL-6 （r = 0.526, P0.01）, TNF-＇（r = 0.511, P0.01）, BUN （r = 0.279, P0.05）, Scr （r = 0.287, P0.05）, PTH （r =0.341, P0.05） and dialysis age （r = 0.298, P0.05）, negatively correlated with the nutritional status indicators of serum ALB （r = -0.573, P0.05） and TRF （r = -0.46, P0.01）, as well as HCO3- （r = - 0.479, P0.01）, but did not correlate with Hb and patients＇age. （c） We compared 15 patients taking ACEI/ARB for more than 3 months in the ACEI/ARB （＋） subgroup and 14 patients in the ACEI/ARB （-） subgroup. When comparisons were made between ACEI/ARB （＋） subgroup and ACEI/ARB（-） subgroup, serum CRP [（0.55±0.32）mg/L vs. （10.07±9.34）mg/L, P0.05], IL-6 [（9.66±4.53）pg/ml vs. （14.24±6.69）pg/ml, P0.05] and TNF-＇[（26.36±11.25）pg/ml vs. （38.35±16.46）pg/ml, P 0.05] were reduced in ACEI/ARB （＋） subgroup, but age, gender and dialysis age had no significant differences between the two subgroups. Conclusions （a） Higher levels of serum CRP, IL-6 and TNF-＇suggest the existence of micro-inflammatory state in MHD patients. Serum CRP is a better marker for micro-inflammatory state, and its level correlated with dialysis age, serum PTH and HCO3-. （b） Micro-inflammatory state has an important impact on nutritional status in MHD patients. （c） ACEI/ARB medications improve the micro-inflammatory state.