【摘要】目的探讨维持性血液透析(maintenance hemodialysis,MHD)患者全血锌与贫血的关系。方法单中心横断面研究，纳入2019 年9 月在广州市红十字会医院血液净化中心行MHD 的患者150 例，记录临床资料和用药情况，测定透析前血常规、血清生化指标和全血锌。将患者分为贫血组(98 例)和非贫血组(52 例)，比较2 组临床特征，应用单变量和多变量分析明确贫血的相关因素；采用受试者工作特征曲线(ROC)分析全血锌对贫血的诊断价值。结果与非贫血组相比，贫血组有较低的全血锌(t=0.608，P＜0.001)；spearman 法分析显示全血锌和血红蛋白呈正相关(r=0.711,P＜0.001)；多因素二分类logistic回归提示，较低的全血锌和女性均是MHD 患者发生贫血的独立相关因素(OR=0.331,95% CI:0.219～0.502，P＜0.001;OR=2.770,95% CI:1.0147～6.690,P=0.024)。ROC 曲线提示全血锌诊断MHD 患者贫血的最佳临界值为5.95mg/L(AUC=0.824,95% CI:0.755～0.893,P＜0.001)。结论较低的全血锌是MHD患者发生贫血的独立影响因素，保持全血锌高于5.95mg/L 可能减少贫血风险。
【Abstract】Objective To explore the relationship between whole blood zinc level and anemia in maintenance hemodialysis (MHD) patients. Methods This single- center and cross- sectional study included 150 MHD patients treated in Guangzhou Red Cross Hospital in September 2019. Clinical data and medications were collected, and blood routine, serum biochemical indexes and whole blood zinc were measured before dialysis. The patients were divided into 2 groups: the anemia group (n=98) and the non-anemia group (n=52). Clinical characteristics of the two groups were analyzed. Univariate and multivariate analyses were used to determine the relevant factors of anemia. The value of whole blood zinc for the diagnosis of anemia was analyzed by receiver operating characteristic curve (ROC). Results Compared with the non-anemic group, the anemic group had lower whole blood zinc (t=0.608, P<0.001). Spearman analysis showed positive correlation between whole blood zinc level and Hb (r=0.711, P<0.001). Multivariate dichotomous logistic regression indicated that low whole blood zinc and gender were the independently related factors for anemia in MHD patients (OR=0.331, 95% CI:0.219～0.502, P<0.001; OR=2.770, 95% CI：1.0147～6.690, P=0.024). ROC curve suggested that the optimal threshold of whole blood zinc level for the diagnosis of anemia in MHD patients was 5.95mg/L (AUC=0.824, 95% CI：0.755-0.893, P<0.001). Conclusion Low whole blood zinc is an independent factor for anemia in MHD patients. Keeping whole blood zinc above 5.95mg/L may reduce the risk of anemia.
[1]Bozalio?lu, S; Ozkan, Y; Turan, M; et al.Prevalence of zinc deficiency and immune response in short-term hemodialysis[J].J Trace Elem Med Biol, 2005, 18(3):243-249
[2]Szpanowska-Wohn, A; Kolarzyk, E; Chowaniec, E.Estimation of intake of zinc,copper and iron in the diet of patients with chronic renal failure treated by haemodialysis[J].Biol Trace Elem Res, 2008, 124(2):97-102
[3]Veighey, K; Booth, J; Davenport, A.Does the choice of phosphate binder affect trace element levels in chronic kidney disease patients treated by regular haemodialysis?[J].Nephrol Dial Transplant.; (3), 2011, 26(3):1006-1010
[4]Ribeiro, RC; Sales, VS; Neves, Fde A.Effects of zinc on cell-mediated immunity in chronic hemodialysis patients[J].Biol Trace Elem Res, 2004, 98(3):209-218
[5]Guo, CH;Wang, CL.Effects of zinc supplementation on plasma copper/zinc ratios, oxidative stress, and immunological status in hemodialysis patients[J].Int J Med Sci, 2013, 10(1):79-89
[6]Yang, CY; Wu, ML; Chou, YY; et al.Essential trace element status and clinical outcomes in long-term dialysis patients: a two-year prospective observational cohort study[J].Clin Nutr, 2012 Oc, 31(5):630-636
[7]Cabral, PC; Diniz, Ada S; de Arruda, IK.Vitamin A and zinc status in patients on maintenance haemodialysis[J].Nephrology (Carlton), 2005, 10(5):459-463
[8]Randrianarison-Huetz, V; Laurent, B; Bardet, V; et al.Gfi-1B controls human erythroid and megakaryocytic differentiation by regulating TGF-beta signaling at the bipotent erythro-megakaryocytic progenitor stage[J].Blood, 2010, 115(14):2784-2795
[9]Kidney Disease: Improving Global Outcomes KDIGOCKD-MBD Update Work Group.KDIGO 2017 Clinical Practice Guide-line Update for the Diagnosis,Evaluation,Prevention,and Treatment of Chronic Kidney Disease-mineral and Bone Disorder(CKD-MBD)[J].Kidney Int Suppl, 2017, 7(3):1-59
[10]中华医学会肾脏病学分会肾性贫血诊断和治疗共识专家组.肾性贫血诊断与治疗中国专家共识修订版[J].中华肾脏病杂志, 2018, 34(11):860-866
[11]国家肾脏疾病临床医学研究中心.中国慢性肾脏病矿物质和骨异常诊治指南概要[J].肾脏病与透析肾移植杂志, 2019, 28(1):52-57
[12]Fuller, DS; Pisoni, RL; Bieber, BA; et al.The DOPPS practice monitor for U.S. dialysis care: update on trends in anemia management 2 years into the bundle[J].Am J Kidney Dis, 2013, 62(6):1213-1216
[13]何琴, 蔡宏, 张伟明, 等.维持性血液透析患者贫血状况与预后的关系[J].中华肾脏病杂志, 2016, 32(2):110-117
[14]徐丽霞, 梁馨苓, 史伟.维持性血液透析患者贫血:指南解读[J].中国血液净化, 2014, 13(01):27-30
[15]Kido, R; Akizawa, T; Fukuhara, S.Haemoglobin concentration and survival of haemodialysis patients before and after experiencing cardiovascular disease: a cohort study from Japanese dialysis outcomes and practice pattern study (J-DOPPS)[J].BMJ Open, 2019, 9(9):e031476-.
[16]Pan, CF; Lin, CJ; Chen, SH.Association between trace element concentrations and anemia in patients with chronic kidney disease: a cross-sectional population-based study[J].J Investig Med, 2019, 67(6):995-1001
[17]Wang, LJ; Wang, MQ; Hu, R; et al.Effect of Zinc Supplementation on Maintenance Hemodialysis Patients: A Systematic Review and Meta-Analysis of 15 Randomized Controlled Trials[J].Biomed Res Int, 2017; 2017:1024769., :-
[18]Tonelli, M; Wiebe, N; Hemmelgarn, B; et al.Trace elements in hemodialysis patients: a systematic review and meta-analysis[J]. BMC Med, 2009 May 19; 7:25., :-
[19]Wang, CL; Lin, KP; Hsu, GW; et al.[J]., , 193(1):14-22[J].Biol Trace Elem Res, 2020 Jan, 193(1):14-22
[20]Dvornik, S; Cuk, M; Racki, S; et al.Serum zinc concentrations in the maintenance hemodialysis patients[J].Coll Antropol, 2006 Mar, 30(1):125-129
[21]Mills-Davies, N;Butler, D;Norton, E.Structural studies of substrate and product complexes of 5-aminolaevulinic acid dehydratase from humans, Escherichia coli and the hyperthermophile Pyrobaculum calidifontis[J].Acta Crystallogr D Struct Biol, 2017 Jan, 73(1):9-21
[22]Tanimura, N; Liao, R; Wilson, GM; et al.GATAHeme Multi-omics Reveals a Trace Metal-Dependent Cellular Differentiation Mechanism[J].Dev Cell, 2018, 46(5):581-594
[23]Osawa, M; Yamaguchi, T; Nakamura, Y; et al.Erythroid expansion mediated by the Gfi-1B zinc finger protein: role in normal hematopoiesis[J].Blood, 2002, 100(8):2769-2777
[24]Fukushima, T; Horike, H; Fujiki, S; et al.Zinc deficiency anemia and effects of zinc therapy in maintenance hemodialysis patients[J].Ther Apher Dial, 2009, 13(3):213-219
[25]杨丽, 王朝旭, 肖飞.不同锌营养状况对大鼠铁代谢的影响[J].卫生研究, 2013, 42(04):647-651
[26]Kobayashi, H; Abe, M; Okada, K; et al.Oral zinc supplementation reduces the erythropoietin responsiveness index in patients on hemodialysis[J].Nutrients, 2015, 7(5):3783-3795
[27]富玲, 安利, 王晓敏, 等.环孢素联合雄激素及糖皮质激素治疗获得性纯红细胞再生障碍性贫血[J].中华临床医师杂志电子版, 2010, 4(12):2577-2578
