【摘要】目的探讨维持性血液透析(maintenance hemodialysis，MHD)患者中性粒细胞淋巴细胞比值(neutrophils-to-lymphocytes ratio，NLR)、营养状态与腹主动脉钙化(abdominal aortic calcification，AAC)的关系，同时分析影响AAC 的危险因素。方法选取2019 至2020 年在徐州医科大学附属医院血液净化中心治疗的MHD 患者。收集患者的一般临床资料及实验室检查结果，用腹部侧位X 线平片检查患者AAC 的情况。老年营养风险指数(geriatric nutritional risk index，GNRI)评估患者营养状况。根据是否发生腹主动脉钙化将患者分为非钙化组和钙化组。比较两组间各指标的差异，采用二元Logistic 回归分析法探讨AAC 发生的危险因素。结果共纳入72 例MHD 患者，钙化组37 例，非钙化组35 例。与非钙化组相比，钙化组年龄、糖尿病患病率、甲状旁腺激素（parathyroid hormone, PTH）、C 反应蛋白（C-creative protein, CRP）、NLR 均明显升高（t/Z/χ2值分别为3.194, 4.766, 2.698, 2.587, 2.943；P值分别为0.002, 0.029, 0.007, 0.010, 0.004），白蛋白（Z=﹣2.947，P=0.003）、GNRI（χ2=﹣2.475，P=0.016）明显降低。Spearman 相关性分析显示AAC 与年龄、PTH、NLR、CRP 呈正相关（r 值分别为0.343，0.320，0.307，0.293；P 值分别为0.003, 0.006, 0.009, 0.010），与白蛋白（r=-0.350，P=0.003）、GNRI（r=-0.263，P=0.026）呈负相关。Logistic 回归分析发现：年龄（OR=1.077，95% CI:1.017～1.141, P=0.012）、糖尿病（OR=4.545, 95% CI：1.032～20.007, P=0.045）、NLR（OR=2.463, 95%CI：1.317～4.608, P=0.005）为AAC 的危险因素，白蛋白水平升高则为AAC 的保护性因素（OR=0.870，95%CI：0.771～0.982，P=0.024）。结论 NLR 及营养不良与MHD 患者AAC 相关。年龄、糖尿病、白蛋白水平及NLR是AAC 的独立危险因素。
【Abstract】Objective To investigate the relationship between neutrophils-lymphocytes ratio (NLR), nutritional status and abdominal aortic calcification (AAC) in maintenance hemodialysis (MHD) patients, and to analyze the risk factors of AAC. Methods MHD patients treated in the Blood Purification Center of the Affiliated Hospital of Xuzhou Medical University from 2019 to 2020 were selected. The clinical data and laboratory examination results of patients were collected, and the AAC of patients was examined by abdominal lateral X-ray film. The geriatric nutritional risk index (GNRI) was used to evaluate patients’nutritional status. According to whether abdominal aortic calcification occured, the patients were divided into non- calcification group and calcification group. The differences of indices between the two groups were compared, and binary Logistic regression analysis was used to explore the risk factors of AAC. Results A total of 72 patients with MHD were included, divided into calcification group (n= 37) and non-calcification group (n=35). Compared with the non-calcified group, patients in calcification group were older, with higher proportion of diabetes mellitus, and with higher parathyroid hormone (PTH), C-creative protein (CRP) and NLR, lower albumin, GNRI (P＜0.05). Correlation analysis showed that AAC was positively correlated with age, PTH, CRP and NLR, but negatively correlated with Alb and GNRI (P＜0.05). Logistic regression analysis showed that age, diabetes mellitus, lower albumin and higher NLR were independent risk factors for abdominal aortic calcification.Conclusions NLR and malnutrition status are associated with AAC in patients with MHD. Old age, diabetes mellitus, lower albumin and higher NLR are independent risk factors for abdominal aortic calcification.
[1]Weiner D E, Tighiouart H, Amin M G, et al. Chronic kidney disease as a risk factor for cardiovascular disease and all-cause mortality: a pooled analysis of community-based studies[J].J Am Soc Nephrol, 2004,15(5):1307-1315. DOI:10.1097/01.asn.000012369 1.46138. e2.
[2]Bolland M J, Wang T K, van Pelt N C, et al. Abdominal aortic calcification on vertebral morph- ometry images predicts incident myocardial infarction[J]. J Bone Miner Res, 2010, 25(3): 505-512.DOI:10.1359/jbmr.091005.
[3]Okuno S, Ishimura E, Kitatani K, et al. Presence of abdominal aortic calcification is significantly associated with all-cause and cardiovascular mortality in maintenance hemodialysis patients[J]. Am J Kidney Dis, 2007,49(3):417-425. DOI:10.1053/j. ajkd.2006. 12.017.
[4]Chen H C, Wang W T, Hsi C N, et al. Abdominal aortic calcification score can predict future coronary artery disease in hemodialysis patients: a 5-year prospective cohort study[J]. BMC Nephrol, 2018,19(1):313.DOI:10.1186/s12882-018-1124-x.
[5]Toussaint N D, Lau K K, Strauss B J, et al. Effect of alendronate on vascular calcification in CKD stages 3 and 4: a pilot randomized controlled trial[J]. Am J Kidney Dis, 2010,56(1):57-68. DOI :10.1053/j.ajkd.2009.12.039.
[6]Turkmen K, Ozcicek F, Ozcicek A, et al. The relationship between neutrophil-to-lymphocyte ratio and vascular calcification in end-stage renal disease patients[J]. Hemodial Int, 2014, 18 (1):47-53. DOI:10.1111/hdi.12065.
[7]Ishii H, Takahashi H, Ito Y, et al. The Association of Ankle Brachial Index, Protein-Energy Wasting, and Inflammation Status with Cardiovascular Mortality in Patients on Chronic Hemo- dialysis[J]. Nutrients, 2017,9(4).DOI:10.3390/nu9040416.
[8]Harada K, Suzuki S, Ishii H, et al. Nutrition Status Predicts Severity of Vascular Calcification in Non-Dialyzed Chronic Kidney Disease[J]. Circ J, 2017,81(3):316-321.DOI:10.1253/circj. CJ-16 -0911.
[9]Yamada K, Furuya R, Takita T, et al. Simplified nutritional screening tools for patients on maintenance hemodialysis[J]. Am J Clin Nutr, 2008,87(1):106-113. DOI:10.1093/ajcn/ 87.1.106.
[10]Kauppila L I, Polak J F, Cupples L A, et al. New indices to classify location, severity and progre- ssion of calcific lesions in the abdominal aorta: a 25-year follow-up study[J]. Atherosclerosis, 19 97 ,132(2):245-250.DOI:10.1016/s0021-9150(97)00106-8.
[11]Yamada K, Furuya R, Takita T, et al. Simplified nutritional screening tools for patients on maintenance hemodialysis[J]. Am J Clin Nutr, 2008,87(1):106-113.DOI:10.1093/ajcn /87.1.106.
[12]陈洁, 陈妙, 应一樱, 等. 冠状动脉钙化积分对于透析患者心血管事件发生风险的预测价值[J]. 中华全科医学, 2019,17(11):1856-1859.
[13]KDIGO clinical practice guideline for the diagnosis, evaluation, prevention, and treatment of Chronic Kidney Disease-Mineral and Bone Disorder (CKD-MBD)[J]. Kidney Int Suppl, 2009 (113):S1-S130.DOI:10.1038/ki.2009.188.
[14]Dentali F, Conte G, Guasti L. Neutrophil-to-lymphocyte ratio: a new prognostic factor even in patients with heart failure[J]. Pol Arch Med Wewn, 2016,126(3):116-117.DOI:10.20452 / p- amw .3331.
[15]Turkmen K, Guney I, Yerlikaya F H, et al. The relationship between neutrophil-to-lym- phocyte ratio and inflammation in end-stage renal disease patients[J]. Ren Fail, 2012,34 (2):155-159. DOI:10.3109/0886022X.2011.641514.
[16]Turkmen K, Ozcicek F, Ozcicek A, et al. The relationship between neutrophil-to-lymphocyte ratio and vascular calcification in end-stage renal disease patients[J]. Hemodial Int, 2014,18(1):47-53. DOI:10.1111/hdi.12065.
[17]Zhou S, Cai B, Zhang Y, et al. The Relationship between Neutrophil-to-Lymphocyte Ratio and Aortic Arch Calcification in Ischemic Stroke Patients[J]. J Stroke Cerebrovasc Dis, 2017,26 (6):1228-1232.DOI:10.1016/j.jstrokecerebrovasdis.2017.01.012.
[18]Wang Y, Miao Y, Gong K, et al. Plasma Complement Protein C3a Level Was Associated with Abdominal Aortic Calcification in Patients on Hemodialysis[J]. J Cardiovasc Transl Res, 2019, 12(5):496-505.DOI:10.1007/s12265-019-09885-2.
[19]Henaut L, Sanchez-Nino M D, Aldamiz-Echevarria C G, et al. Targeting local vascular and systemic consequences of inflammation on vascular and cardiac valve calcification[J]. Expert Opin Ther Targets, 2016,20(1):89-105.DOI:10.1517/14728222.2015.1081685.
[20]Henaut L, Mary A, Chillon J M, et al. The Impact of Uremic Toxins on Vascular Smooth Muscle Cell Function[J]. Toxins (Basel), 2018,10(6).DOI:10.3390/toxins10060218.
[21]Gama-Axelsson T, Heimburger O, Stenvinkel P, et al. Serum albumin as predictor of nutritional status in patients with ESRD[J]. Clin J Am Soc Nephrol, 2012,7(9):1446-1453. DOI:10. 2215 /CJN.10251011.
[22]Kaysen G A, Chertow G M, Adhikarla R, et al. Inflammation and dietary protein intake exert competing effects on serum albumin and creatinine in hemodialysis patients[J]. Kidney Int, 2001,60(1):333-340.DOI:10.1046/j.1523-1755.2001.00804.x.
[23]Tentori F, Hunt W C, Rohrscheib M, et al. Which targets in clinical practice guidelines are associated with improved survival in a large dialysis organization?[J]. J Am Soc Nephrol, 2007,18(8):2377-2384.DOI:10.1681/ASN.2006111250.
[24]Zhang K, Cheng G, Cai X, et al. Malnutrition, a new inducer for arterial calcification in hemodialysis patients?[J]. J Transl Med, 2013,11:66.DOI:10.1186/1479-5876-11-66.
[25]Mehrotra R, Duong U, Jiwakanon S, et al. Serum albumin as a predictor of mortality in peritoneal dialysis: comparisons with hemodialysis[J]. Am J Kidney Dis, 2011,58(3):418-428. DOI:10.1053 /j.ajkd.2011.03.018.
[26]Guo J, Zeng M, Zhang Y, et al. Serum Alkaline Phosphatase Level Predicts Cardiac Valve Calcification in Maintenance Hemodialysis Patients[J]. Blood Purif, 2020:1-10.DOI:10. 1159 /000505846.
[27]Panichi V, Cupisti A, Rosati A, et al. Geriatric nutritional risk index is a strong predictor of mortality in hemodialysis patients: data from the Riscavid cohort[J]. J Nephrol, 2014,27(2):193 -201. DOI:10.1007/s40620-013-0033-0.
[28]莫颖, 任荣, 张艳. 血清胎球蛋白A、C反应蛋白及骨保护素水平与血液透析患者血管钙化相关性研究[J]. 临床肾脏病杂志, 2019,19(11):853-856.
