【摘要】目的本研究旨在探讨新进入腹膜透析人群中甲状旁腺激素水平分布，影响因素，及其对腹膜透析患者长期生存的影响。方法新进入腹膜透析治疗的成人终末期肾病患者按患者全段甲状旁腺激素(intact parathyroid hormone，iPTH)水平分为A 组iPTH＜150 pg/ml；B 组iPTH 150～300pg/ml；C 组iPTH 300～600pg/ml；D 组iPTH ≥600pg/ml。比较各组患者的临床及化验资料；使用多元线性回归筛选与基线iPTH 相关的危险因素。应用COX 回归模型分析影响生存率的因素。应用Kaplan-Meier 生存分析、COX 回归模型分析比较4 组患者的生存情况。结果共222 例腹膜透析患者入选。其中，基线iPTH＜150pg/ml 的患者占43.7%。这组患者的特点包括：年龄大(F=6.235, P＜0.001)，合并糖尿病比例高(F=16.277, P=0.001)，合并症多(F=4.348, P=0.005)，eGFR 较高(F= 5.699, P=0.001)。但经过元线性回归分析，仅年龄(β=-8.700, P＜0.001)、是/否合并糖尿病(β=145.400, P =0.012)对基线iPTH 有独立的影响。生存曲线显示不同基线iPTH 组间总体生存率存在差异(P =0.002)。多因素COX 回归分析发现，仅年龄(B=0.066,P＜0.001)是预测死亡的独立危险因素，基线iPTH(B＜0.001,P=0.507)不能独立预测死亡。结论初进入腹膜透析治疗的患者中，年龄大、合并糖尿病的患者，更容易出现低iPTH 的情况。但是，基线iPTH并不能独立预测死亡。
【Abstract】Objective The purpose of this study was to investigate the changes of serum intact parathyroid hormone (iPTH) and its related factors in incident peritoneal dialysis (PD) patients, and to assess its impact on long-term survival of PD patients. Methods Clinical data were analyzed for all adult chronic renal failure patients initiating PD therapy. According to the iPTH level, patients were divided into four groups: group A (iPTH ＜150pg/ml), group B (iPTH 150~300pg/ml), group C (iPTH 300~ 600 pg/ml), and group D (iPTH ≥600pg/ml). Variance analysis and χ2 test were used to compare the clinical and laboratory data of the four groups. Multiple linear regression was used to screen the risk factors for baseline iPTH level. Cox regression model was used to analyze the factors for survival rate. Kaplan-Meier survival analysis and Cox regression model were used to compare the survival rate of the four groups. Results This study enrolled 222 patients, in which baseline iPTH <150 pg/ml accounted for 43.7% of the patients. The patients with baseline iPTH <150 pg/ml had the characteristics of older age (F=6.235, P<0.001), higher incidence of diabetes mellitus (F=16.277, P=0.001), more complications (F=4.348, P=0.005), and higher eGFR (F= 5.699, P=0.001). However, multiple linear regression revealed that only age (β =- 8.700, P＜0.001) and diabetes mellitus
(β=145.400, P=0.012) had the independent effects on baseline iPTH level. Kaplan- Meier survival curve showed that the survival rate was different among the four groups (P=0.002). Multivariate COX regression showed that only age (β=0.066, P< 0.001) was the independent risk factor for predicting mortality, and baseline iPTH level (P=0.507) could not independently predict mortality. Conclusion The incident PD patients with older age and diabetes mellitus were more likely to have lower baseline iPTH. However, baseline iPTH level could not independently predict mortality.
[1]刘志红. 中华医学会肾脏病学分会慢性肾脏病矿物质和骨异常诊治指导[C]// 中华医学会肾脏病学分会2013年学术年会. 2013.
[2]Kong X, Zhang L, Zhang L, et al. Mineral and bone disorder in Chinese dialysis patients: a multicenter study[J]. Bmc Nephrology, 2012, 13(1):116.
[3]Crepaldi C , Possidoni A , Caputo F , et al. Clinical management of patients on peritoneal dialysis in Italy: results from the ATENA study[J]. Clinical Kidney Journal, 2018, 11(2):275-282.
[4]Fouque D , Roth H , Darn?? B, et al. Achievement of Kidney Disease: Improving Global Outcomes mineral and bone targets between 2010 and 2014 in incident dialysis patients in France: the Photo-Graphe3 study:[J]. Clin Kidney J, 2018, 11(1):73-79.
[5]Yamamoto S , Karaboyas A , Komaba H , et al. Mineral and bone disorder management in hemodialysis patients: comparing PTH control practices in Japan with Europe and North America: the Dialysis Outcomes and Practice Patterns Study (DOPPS)[J]. BMC Nephrology, 2018, 19(1): 253.
[6]István Kiss, Zoltán Kiss, Ambrus C , et al. Age-dependent parathormone levels and different CKD-MBD treatment practices of dialysis patients in Hungary - results from a nationwide clinical audit[J]. BMC Nephrology, 2013, 14.
[7]杨娟, 杨光, 张波,等. 糖尿病维持性血液透析患者甲状旁腺激素及25羟维生素D3水平的改变及相关因素分析[J]. 中国血液净化, 2016, 15(12):682-685.
[8]卢元, 胡晓舟, 张瑾,等. 维持性血液透析患者继发性甲状旁腺功能亢进相关因素分析[J]. 实用医学杂志, 2015, 31(16):2684-2687.
[9]Tentori F, Blayney MJ, Albert JM, et al. Mortality risk for dialysis patients with different levels of serum calcium, phosphorus, and PTH: the Dialysis Outcomes and Practice Patterns Study (DOPPS). Am J Kidney Dis, 2008, 52(3):519-530.
[10] Naves-Diaz M, Passlick-Deetjen J, Guinsburg A, et al. Calcium, phosphorus, PTH and death rates in a large sample of dialysis patients from Latin America. The CORES Study. Nephrol Dial Transplant, 2011, 26(6):1938-1947.
[11] Floege J, Kim J, Ireland E, et al. Serum iPTH, calcium and phosphate, and the risk of mortality in a European haemodialysis population. Nephrol Dial Transplant, 2011, 26(6):1948-1955.
[12]Fernándezmartín J L, Martínezcamblor P, Dionisi M P, et al. Improvement of mineral and bone metabolism markers is associated with better survival in haemodialysis patients: the COSMOS study[J]. Nephrology, dialysis, transplantation : official publication of the European Dialysis and Transplant Association - European Renal Association, 2015, 30(9):1542-1551.
[13]Saab G, Bomback AS, McFarlane SI, et al. The association of parathyroid hormone with ESRD and pre-ESRD mortality in the Kidney Early Evaluation Program. J Clin Endocrinol Metab, 2012, 97(12):4414-4421.
[14]Block G A, Klassen P S, Lazarus J M, et al. Mineral metabolism, mortality, and morbidity in maintenance hemodialysis.[J]. Journal of the American Society of Nephrology, 2004, 15(8):2208-2218.
[15]Slinin Y, Foley RN, Collins AJ. Calcium, phosphorus, parathyroid hormone, and cardiovascular disease in hemodialysis patients: the USRDS waves 1, 3, and 4 study. J Am Soc Nephrol, 2005, 16(6):1788-1793.
[16]Stevens LA, Djurdjev O, Cardew S, et al. Calcium, phosphate, and parathyroid hormone levels in combination and as a function of dialysis duration predict mortality: evidence for the complexity of the association between mineral metabolism and outcomes. J Am Soc Nephrol,2004, 15(3):770-779.
[17]Jean G, Lataillade D, Genet L, et al. Association between very low PTH levels and poor survival rates in haemodialysis patients: results from the French ARNOS cohort. Nephron Clin Pract, 2011, 118(2):c211-216.
[18]Rhee H, Song SH, Kwak IS, et al. Persistently low intact parathyroid hormone levels predict a progression of aortic arch calcification in incident hemodialysis patients. Clin Exp Nephrol, 2012, 16(3):433-441.
[19]Guillaume J, Jean-Claude S, Eric Z, et al. Analysis of the kinetics of the parathyroid hormone, and of associated patient outcomes, in a cohort of haemodialysis patients:[J]. Bmc Nephrology, 2016, 17(1):153.
[20]Liu C T , Lin Y C , Lin Y C , et al. Roles of Serum Calcium, Phosphorus, PTH and ALP on Mortality in Peritoneal Dialysis Patients: A Nationwide, Population-based Longitudinal Study Using TWRDS 2005–2012[J]. Scientific Reports, 2017, 7(1):33.
