【摘要】目的分析兰州大学第二医院肾病内科血液透析中心维持性血液透析(maintenance hemodialysis, MHD)患者长期生存期的重大危险事件及影响因素。方法将2014 年7 月～2019 年7 月在兰州大学第二医院肾病内科血液透析中心MHD 患者纳入研究。结果筛选出168 例患者，男性占63.10%，女性占36.90%。MHD 患者生存期间最常见的重大危险事件为心脑血管事件及血管通路问题(均占
17.04%)，其次肺部感染(14.38%)。心脑血管事件组的患者年龄较高(Z=-2.489,P=0.013)，带隧道带涤纶套导管(catheter with cuff, CVC)占比高(c2=5.080, P=0.024)，血红蛋白(hemoglobin, Hb)(t=2.465, P=0.015)、尿素氮(blood urea nitrogen,BUN) (t=2.736, P= 0.007)、血肌酐(serum creatinine,Scr) (Z=-3.067,P=0.002)、总胆固醇(total cholesterol,TC)(t=2.291,P=0.023)水平低。肺部感染组患者的年龄较高(Z=-2.272,P=0.023)，CVC 占比高(c2=10.510，P=0.001)，Hb(Z=-2.418,P=0.016)、血清白蛋白(serum albumin, ALB) (Z=-2.087,P=0.037)水平低。血管通路事件组的女性患者占比高(c2=11.191, P=0.001)，CVC 占比高(c2=38.768，P＜0.001)，Hb(t=2.551, P=0.012)、BUN(t=2.210, P=0.028)、Scr (Z=- 2.408, P=0.016)水平低。重度贫血组女性患者占比高(c2=12.196, P＜0.001)，CVC 占比高(c2=11.419,P=0.001)，Hb(t=5.048,P＜0.001)、Scr(Z=- 3.643,P＜0.001)、ALB(Z=- 2.324,P=0.020)、血磷
(serum phosphate,P)(t=2.821,P=0.005)水平低。多元Logistic 回归分析提示：TC(OR=0.685，95% CI:0.481～0.977，P=0.037)是MHD 患者发生心脑血管疾患的独立危险因素。CVC 是MHD 患者合并肺部感染(OR=2.948，95% CI:1.248～6.961，P=0.014)及并发血管通路问题(OR=11.164，95% CI:4.125～30.219，P＜0.001)的独立危险因素。高全段甲状旁腺素(intact parathyroid hormone, iPTH)水平是MHD 患者发生重度贫血的危险因素(OR=1.001，95% CI:1.000～1.002，P=0.013)。结论关注MHD 患者的心脑血管及肺部健康问题，建议无特殊情况时MHD 患者的通路以动静脉内瘘为主，重视女性患者血管通路的选择及贫血监测。
【Abstract】Objective To analyze the major risk events and the influencing factors of maintenance hemodialysis patients(MHD)in the Lanzhou University Second Hospital hemodialysis center. Methods MHD patients were included in the hemodialysis center of Lanzhou university second hospital from July 2014 to July 2019. Results 168 patients were enrolled, including 63.10% males. The most common major risk events occurred in MHD patients were cardiovascular and cerebrovascular events (17.04%), vascular access problems (17.04%), followed by pulmonary infection (14.38%). Patients in the cardio-cerebrovascular event group were
older (Z=-2.489, P=0.013),with hogher proportion of catheter with cuff (CVC)(c2=5.080,P=0.024), and with lower hemoglobin (Hb) (t=2.465,P=0.015), blood urea nitrogen (BUN) (t=2.736,P=0.007), serum creatinine (Scr) (Z=- 3.067,P=0.002), and total cholesterol(TC) (t=2.291,P=0.023). Patients in the lung infection group were older (Z=-2.272,P=0.023), with higher proportion of CVC (c2=10.510, P=0.001),and with lower Hb (Z=-2.418,P=0.016) and serum albumin(ALB) (Z=-2.087,P=0.037). In the vascular access event group, the proportion of females was higher (c2=11.191,P=0.001) ,the proportion of CVC was higher (c2=38.768,P＜0.001), and Hb (t=2.551,P=0.012),BUN (t=2.210,P=0.028),Scr (Z=-2.408,P=0.016) levels were lower. In the severe anemia group, the proportion of females was higher (c2=12.196, P＜0.001),the proportion of CVC was higher (c2=11.419,P=0.001), and the levels of Hb (t=5.048, P＜0.001), Scr (Z=-3.643, P＜0.001), ALB (Z=-2.324, P=0.020) and serum phosphate (P) (t=2.821, P= 0.005) were lower. Multivariate Logistic regression analysis indicated that in MHD patients, TC (OR=0.685,95% CI:0.481～0.977, P=0.037) was an independent risk factor for cardio-cerebrovascular diseases. CVC was an independent risk of pulmonary infection (OR=2.948,95% CI:1.248～6.961,P=0.014) and vascular access problems (OR=11.164, 95% CI:4.125～30.219, P＜0.001) in
MHD patients. High intact parathyroid hormone (iPTH) level was a risk factor for severe anemia in MHD patients (OR=1.001,95% CI:1.000～1.002, P=0.013). Conclusion We need pay more attention to the cardiocerebrovascular and pulmonary health problems in MHD patients. It is recommended that if there are no special issues, the arteriovenous fistulas should be the first choice for MHD patients. In addition, we need to pay more attention to the choice of vascular access and the monitoring of anemia in female patients.
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