中华危重病急救医学
中華危重病急救醫學
중화위중병급구의학
Chinese Critical Care Medicine
2015年
5期
354-358
,共5页
华锦程%梁萌%沈淑琼%李彩凤%许树根
華錦程%樑萌%瀋淑瓊%李綵鳳%許樹根
화금정%량맹%침숙경%리채봉%허수근
维持性血液透析%短期死亡%终末期肾病%感染%心脑血管疾病
維持性血液透析%短期死亡%終末期腎病%感染%心腦血管疾病
유지성혈액투석%단기사망%종말기신병%감염%심뇌혈관질병
Hemodialysis%Early death%End-stage renal disease%Infection%Cardiovascular and cerebrovascular disease
目的：探讨维持性血液透析（MHD）患者短期死亡（透析后3～12个月内死亡）的原因及相关影响因素，为防治短期死亡提供科学依据。方法采用回顾性病例对照分析方法，以解放军第一七四医院血液透析中心2004年1月至2014年4月开始MHD并于3～12个月内死亡的51例患者作为病例组，按1∶2匹配对照的方法选择与其同期开始MHD（±2个月）且生存时间超过12个月的102例患者作为对照组。所有患者均规律透析（每周2～3次），常规限制水钠摄入，给予控制血压、纠正贫血、纠正钙磷代谢紊乱等基础治疗。分析病例组患者短期死亡的主要原因；收集两组开始接受透析时的各项临床和生化指标，采用单因素、多因素logistic回归分析透析后短期死亡的相关危险因素；绘制受试者工作特征曲线（ROC），判断各指标对MHD患者短期死亡的评估价值。结果51例MHD短期死亡患者的主要死因为心脑血管疾病（27例，占52.9%）、感染（15例，占29.4%）。单因素分析显示，与MHD短期死亡有关的可能因素有年龄〔优势比（OR）＝6.625，95%可信区间（95%CI）＝3.232～13.580，P＝0.000〕、糖尿病（OR＝3.875，95%CI＝0.654～10.622，P＝0.031）、透析前专科干预时间（OR＝0.349，95%CI＝0.287～0.572，P＝0.004）、透析前伴心脑血管疾病（OR＝9.667，95%CI＝4.632～20.174，P＝0.000）、首次透析为急诊透析（OR＝3.875，95%CI＝1.713～8.765，P＝0.005）、白蛋白（OR＝0.294，95%CI＝0.068～0.550，P＝0.008）、白细胞计数（OR＝6.286，95%CI＝1.648～23.982，P＝0.026）、中性粒细胞计数（OR＝2.833，95%CI＝1.630～4.923，P＝0.001）。将单因素分析中有统计学意义的这8个因素作为自变量，在α＝0.05水平上进行非条件logistic回归分析，结果显示，老龄（OR＝1.054，95%CI＝1.019～1.090， P＝0.002）、透析前伴心脑血管疾病（OR＝7.469，95%CI＝2.474～22.545，P＝0.000）是MHD患者短期死亡的危险因素，透析前早期进行专科干预则是保护因素（OR＝0.286，95%CI＝0.113～0.722，P＝0.008）。ROC曲线分析显示，年龄对MHD患者短期死亡具有中等诊断价值〔ROC曲线下面积（AUC）＝0.756〕，截断值为59.0岁时，敏感度为66.7%，特异度为77.5%；透析前专科干预时间的诊断价值相对较低（AUC＝0.367），截断值为0.875年时，敏感度为39.2%，特异度为33.3%。结论老年、透析前伴有心脑血管疾病与MHD患者短期死亡相关，透析前早期进行专科干预可降低短期死亡的风险。
目的：探討維持性血液透析（MHD）患者短期死亡（透析後3～12箇月內死亡）的原因及相關影響因素，為防治短期死亡提供科學依據。方法採用迴顧性病例對照分析方法，以解放軍第一七四醫院血液透析中心2004年1月至2014年4月開始MHD併于3～12箇月內死亡的51例患者作為病例組，按1∶2匹配對照的方法選擇與其同期開始MHD（±2箇月）且生存時間超過12箇月的102例患者作為對照組。所有患者均規律透析（每週2～3次），常規限製水鈉攝入，給予控製血壓、糾正貧血、糾正鈣燐代謝紊亂等基礎治療。分析病例組患者短期死亡的主要原因；收集兩組開始接受透析時的各項臨床和生化指標，採用單因素、多因素logistic迴歸分析透析後短期死亡的相關危險因素；繪製受試者工作特徵麯線（ROC），判斷各指標對MHD患者短期死亡的評估價值。結果51例MHD短期死亡患者的主要死因為心腦血管疾病（27例，佔52.9%）、感染（15例，佔29.4%）。單因素分析顯示，與MHD短期死亡有關的可能因素有年齡〔優勢比（OR）＝6.625，95%可信區間（95%CI）＝3.232～13.580，P＝0.000〕、糖尿病（OR＝3.875，95%CI＝0.654～10.622，P＝0.031）、透析前專科榦預時間（OR＝0.349，95%CI＝0.287～0.572，P＝0.004）、透析前伴心腦血管疾病（OR＝9.667，95%CI＝4.632～20.174，P＝0.000）、首次透析為急診透析（OR＝3.875，95%CI＝1.713～8.765，P＝0.005）、白蛋白（OR＝0.294，95%CI＝0.068～0.550，P＝0.008）、白細胞計數（OR＝6.286，95%CI＝1.648～23.982，P＝0.026）、中性粒細胞計數（OR＝2.833，95%CI＝1.630～4.923，P＝0.001）。將單因素分析中有統計學意義的這8箇因素作為自變量，在α＝0.05水平上進行非條件logistic迴歸分析，結果顯示，老齡（OR＝1.054，95%CI＝1.019～1.090， P＝0.002）、透析前伴心腦血管疾病（OR＝7.469，95%CI＝2.474～22.545，P＝0.000）是MHD患者短期死亡的危險因素，透析前早期進行專科榦預則是保護因素（OR＝0.286，95%CI＝0.113～0.722，P＝0.008）。ROC麯線分析顯示，年齡對MHD患者短期死亡具有中等診斷價值〔ROC麯線下麵積（AUC）＝0.756〕，截斷值為59.0歲時，敏感度為66.7%，特異度為77.5%；透析前專科榦預時間的診斷價值相對較低（AUC＝0.367），截斷值為0.875年時，敏感度為39.2%，特異度為33.3%。結論老年、透析前伴有心腦血管疾病與MHD患者短期死亡相關，透析前早期進行專科榦預可降低短期死亡的風險。
목적：탐토유지성혈액투석（MHD）환자단기사망（투석후3～12개월내사망）적원인급상관영향인소，위방치단기사망제공과학의거。방법채용회고성병례대조분석방법，이해방군제일칠사의원혈액투석중심2004년1월지2014년4월개시MHD병우3～12개월내사망적51례환자작위병례조，안1∶2필배대조적방법선택여기동기개시MHD（±2개월）차생존시간초과12개월적102례환자작위대조조。소유환자균규률투석（매주2～3차），상규한제수납섭입，급여공제혈압、규정빈혈、규정개린대사문란등기출치료。분석병례조환자단기사망적주요원인；수집량조개시접수투석시적각항림상화생화지표，채용단인소、다인소logistic회귀분석투석후단기사망적상관위험인소；회제수시자공작특정곡선（ROC），판단각지표대MHD환자단기사망적평고개치。결과51례MHD단기사망환자적주요사인위심뇌혈관질병（27례，점52.9%）、감염（15례，점29.4%）。단인소분석현시，여MHD단기사망유관적가능인소유년령〔우세비（OR）＝6.625，95%가신구간（95%CI）＝3.232～13.580，P＝0.000〕、당뇨병（OR＝3.875，95%CI＝0.654～10.622，P＝0.031）、투석전전과간예시간（OR＝0.349，95%CI＝0.287～0.572，P＝0.004）、투석전반심뇌혈관질병（OR＝9.667，95%CI＝4.632～20.174，P＝0.000）、수차투석위급진투석（OR＝3.875，95%CI＝1.713～8.765，P＝0.005）、백단백（OR＝0.294，95%CI＝0.068～0.550，P＝0.008）、백세포계수（OR＝6.286，95%CI＝1.648～23.982，P＝0.026）、중성립세포계수（OR＝2.833，95%CI＝1.630～4.923，P＝0.001）。장단인소분석중유통계학의의적저8개인소작위자변량，재α＝0.05수평상진행비조건logistic회귀분석，결과현시，노령（OR＝1.054，95%CI＝1.019～1.090， P＝0.002）、투석전반심뇌혈관질병（OR＝7.469，95%CI＝2.474～22.545，P＝0.000）시MHD환자단기사망적위험인소，투석전조기진행전과간예칙시보호인소（OR＝0.286，95%CI＝0.113～0.722，P＝0.008）。ROC곡선분석현시，년령대MHD환자단기사망구유중등진단개치〔ROC곡선하면적（AUC）＝0.756〕，절단치위59.0세시，민감도위66.7%，특이도위77.5%；투석전전과간예시간적진단개치상대교저（AUC＝0.367），절단치위0.875년시，민감도위39.2%，특이도위33.3%。결론노년、투석전반유심뇌혈관질병여MHD환자단기사망상관，투석전조기진행전과간예가강저단기사망적풍험。
ObjectiveTo explore the cause of early death (death within 3-12 months after hemodialysis) and the related influencing factors patients undergoing maintenance hemodialysis (MHD) as to provide a scientific basis for the prevention of early death.Methods A retrospective matched controlled study was conducted. Fifty-one patients who underwent MHD from January 2004 to April 2014 and died within 3-12 months after hemodialysis in hemodialysis center of the 174th Chinese People's Liberation Army Hospital were included in the case group by retrospective analysis method. According to 1∶2 matched controls, 102 patients underwent hemodialysis in the same period (±2 months) and survived over 12 months were selected as control group. All patients received regular hemodialysis (dialysis 2-3 times per week), with conventional limitation of water and sodium intake, routine treatments such as control of blood pressure, treatment of anemia and disorders of calcium and phosphorus contents. Causes of short-term death were analyzed. Clinical and biochemical parameters of two groups were collected when dialysis was started, and the single factor and multiple factors logistic regression was used to analyze the related risk factors when dialysis was started. Receiver operating characteristic curve (ROC) was plotted to evaluate the value of above parameters in predicting the early death in patents with MHD.Results The main causes of early death of 51 patients with MHD were mainly cardiovascular and cerebrovascular diseases (27 cases, 52.9%), and infections (15 cases, 29.4%). It was shown by single factor analysis that the age [odds ratio (OR) = 6.625, 95% confidence interval (95%CI) = 3.232-13.580,P = 0.000], diabetes (OR = 3.875, 95%CI = 0.654 - 10.622,P = 0.031), specialist intervention time before dialysis (OR = 0.349, 95%CI =0.287 - 0.572,P = 0.004), the emergence of cardiovascular and cerebrovascular events before dialysis (OR = 9.667, 95%CI = 4.632 - 20.174,P = 0.000), the first dialysis for emergency dialysis (OR = 3.875, 95%CI = 1.713 - 8.765, P = 0.005), blood albumin level (OR = 0.294, 95%CI = 0.068 - 0.550,P = 0.008), leukocyte count (OR = 6.286, 95%CI = 1.648 - 23.982,P = 0.026), neutrophil count (OR = 2.833, 95%CI = 1.630 - 4.923,P = 0.001) might be the factors correlating with early death. Eight independent factors were statistically significant, and their effect on the MHD patients was analyzed by logistic regression analysis inα = 0.05 level. The results showed that patients with old age (OR = 1.054, 95%CI = 1.019-1.090,P = 0.002), and the emergence of cardio-cerebrovascular events (OR = 7.469, 95%CI = 2.474 - 22.545,P = 0.000)were early death risk factors of MHD patients, and early specialist intervention before dialysis was a protective factor (OR = 0.286, 95%CI = 0.113-0.722,P = 0.008). ROC curve showed that age had moderate diagnostic value for early death of MHD [area under ROC curve (AUC) = 0.756], the cut-off value was 59.0 years old, the sensitivity was 66.7%, and the specificity was 77.5%. The diagnostic value of early specialist intervention before dialysis was relatively low (AUC = 0.367), the cut-off value was 0.875 years, the sensitivity was 39.2%, and the specificity was 33.3%.Conclusion Old age, the emergency of cardiovascular and cerebrovascular events before dialysis is associated with early death, and specialist intervention ahead of dialysis can reduce the risk of early death.
