终末期肾病慢性腹膜透析患儿贫血影响因素病例对照研究

目的 了解终末期肾病慢性腹膜透析(腹透)患儿贫血的影响因素。方法 回顾性分析2006年1月至2012年4月在复旦大学附属儿科医院（我院）肾脏风湿科登记并行长期规律腹透治疗患儿，腹透后建立随访档案，要求每3个月来我院随访1次，至少随访12个月，并行随访指标的检查。腹透开始前的基线随访指标以例数表现，腹透后随访指标中的计量计数指标（体检项目、实验室检查项目和感染情况）以例次表现，选取每3个月随访时间±3 d时Hb值判断贫血，如符合贫血诊断标准则该阶段随访指标纳入贫血组统计，反之纳入非贫血组统计。 单因素分析采用独立样本t检验，计数资料采用χ2检验，多因素分析采用Logistic回归分析。结果（1）符合本文纳入排除标准的32例患儿进入分析，开始腹透年龄(8.4±3.7)岁,开始腹透前30例（93.8%）存在贫血；开始腹透后共随访120例次，8例次失访，贫血组57例次（47.5%），非贫血组63例次，贫血组Hb、红细胞压积均明显低于非贫血组。（2）单因素分析显示：①基本情况：贫血组与非贫血组相比，腹透时年龄、性别差异无统计学意义（P＞0.05）；②体检项目： BMI、收缩压、舒张压两组差异无统计学意义（P＞0.05）；③实验室检查项目：随访12个月，贫血组血清全段甲状旁腺激素（iPTH）水平高于非贫血组［(605±582) vs （386±434） pg·mL-1, P＜0.05］，血清iPTH在500~1 000 pg·mL-1患儿贫血的发生率显著高于iPTH＜500 pg·mL-1者（P＜0.05）；贫血组残肾Kt/V值低于非贫血组［（0.35±0.42）vs (0.62±0.63),P＜0.05］，左心肥厚的发生率高于非贫血组（62.5% vs 35.1%，χ2=5.758, P=0.016）；贫血组血清白蛋白、总Kt/V、总CrCL、残肾CrCL均低于非贫血组（P＞0.05）,血尿素氮、肌酐均高于非贫血组(P＞0.05)；④ACEI使用率贫血组与非贫血组间差异无统计学意义（P＞0.05）；⑤贫血组元素铁剂量、促红细胞生成素（EPO）剂量均低于非贫血组［元素铁剂量：(3.5±1.9) vs (4.2±1.2) mg·kg-1·d-1; EPO:每周（134±66） vs (170±62) U·kg-1, P＜0.05］；⑥感染发生率贫血组高于非贫血组（35.1% vs 19.0%，P＜0.05）；（3）多元回归分析显示，血清iPTH水平、残肾Kt/V、感染与慢性腹透患儿的贫血具有相关性（P＜0.05）。结论 ①慢性腹透患儿血清iPTH水平、有无感染和残肾Kt/V与贫血具有相关性；②强调EPO、铁剂的个体化治疗，在高血清iPTH水平、感染等情况下，可能需要更大剂量的EPO、铁剂改善贫血；③应加强对慢性肾脏病患儿管理，重视肾性贫血的早期治疗。

Case-control study on anemia influencing factors of children with chronic peritoneal dialysis

Objective To analyze anemia influencing factors of children with chronic peritoneal dialysis.Methods A retrospective review of 32 patients with registration of chronic peritoneal dialysis was carried out at Children's Hospital of Fudan University from January 2006 to April 2012, the follow-up files after dialysis were established, once follow-up was taken every three months in our hospital, duration of follow-up was 12 months at least, follow-up indicators were examined. Baseline follow-up indicators of pre-dialysis were shown by the number of cases, after dialysis the follow-up indicators (medical projects, laboratory projects and infection) were showed by episodes, hemoglobin value of every three months follow-up time ± 3 days was selected to diagnose anemia. If patients met the diagnostic criteria of anemia, this stage of follow-up indicators were included in the anemia group, whereas if the patients did not meet were included in the non-anemic group. SPSS 19.0 software was applied for statistical analysis, the measurement data were compared using Student's t-test, frequency distributions were compared using the chi-square test, multivariate logistic regression analysis was used to identify factors associated with anemia.Results (1)30/32(93.75%) patients met the criteria for anemia at the baseline，57/120(47.5%) episodes still met the criteria for anemia after following up 12 months. Hemoglobin and hematocrit in the anemia group were significantly lower than those in the non-anemic group. (2)Univariate analysis showed that：①Peritoneal dialysis age and sex did not significantly differ (P>0.05). ②There were no siginificant differences in BMI, systolic pressure or diastolic pressure between the anemia group and the non-anemic group (P> 0.05).③Serum parathyroid hormone(PTH) levels in the anemia group were higher than that in the non-anemic group［(605±582) vs（386±434）pg·mL-1］，PTH levels between 500 and 1 000 pg·mL-1 was associated with higher incidence of anemia than PTH levels below 500 pg·mL-1. Residual renal Kt/V in the anemia group was lower than that in the non-anemic group［（0.35±0.42 ）vs (0.62±0.63),P＜0.05］, incidence of left ventricular hypertrophy was higher than that in the non-anemic group（62.5% vs 35.1%，χ2=5.758, P=0.016）. In the anemia group,serum albumin, total Kt/V, total CrCL and residual renal CrCL were lower than those in the non-anemic group（P＞0.05），blood urea nitrogen and serum creatinine were higher than those in the non-anemic group（P＞0.05），the differences were not statistically significant. ④There was no siginificant difference in prescibed ACEI between the anemia group and the non-anemic group (P> 0.05). ⑤In the anemia group ,elemental iron dose and EPO dose were lower than those in the non-anemic group［(3.5±1.9) vs (4.2±1.2) mg·kg-1·d-1，（134±66） vs (170±62) U·kg-1 per week, P＜0.05］. ⑥The incidence of anemia in patients with infection was higher than patients without infection（35.1% vs 19.0%, P＜0.05). (3) Multivariate logistic regression analysis showed that serum iPTH levels, residual renal Kt/V and infection were associated with anemia in chronic PD children ( P<0.05).Conclusion ①In peritoneal dialysis children, the serum iPTH levels, residual renal Kt/V and infection were associated with anemia. ②Erythropoietin and iron to individualized treatment should be emphasized, in the high levels of serum iPTH, infection, and other circumstances, it may require higher doses of erythropoietin and iron improve anemia;③ It is important to pay more attention to the early treatment of renal anemia and management of CKD children.