目的探讨维持性血液透析(maintenancehemodialysis，MHD)患者透析前慢性低钠血症的危险因素。方法选择2017年8月～2020年6月在北京大学国际医院血液净化中心的152例MHD患者进行回顾性研究。全部患者每1～3个月进行1次透析前血钠、血糖、血白蛋白、血碱性磷酸酶及其他实验室检查，计算时间平均血钠(time-averagedserumsodium,TASNa)及其他化验指标的时间平均值，每1～3个月测量1次生物电阻抗分析(bioimpedanceanalysis，BIA)，记录多余水分(overhydration，OH)、细胞外液、细胞内液(intracellularfluid，ICW)以及瘦组织指数(leantissueindex，LTI)等。依据TASNa值分为低钠血症组(TASNa≤135mmol/L)和正常血钠组(135＜TASNa＜145mmol/L)。独立样本t检验或卡方检验比较2组间差异，二元Logistic回归分析透析前慢性低钠血症的危险因素。结果根据TASNa的低钠血症患病率为23.7%，校正血糖后的低钠血症患病率为9.9%。与正常血钠组相比，低钠血症组患者的糖尿病比例更高(χ2=27.134，P＜0.001)，诊室透析前收缩压(t=2.175，P=0.031)、血糖(t=6.408，P＜0.001)以及OH(t=2.930，P=0.004)更高，而血肌酐(t=-4.008，P＜0.001)、血尿素氮(t=-2.169，P=0.032)、血氯(t=-7.898，P＜0.001)、血前白蛋白(t=-3.692，P＜0.001)、血白蛋白(t=-2.170，P=0.032)、血磷(t=-2.476，P=0.014)、血尿酸(t=-2.168，P=0.032)、有效血浆渗透压(t=-3.737，P=0.001)、ICW(t=-2.113，P=0.038)和LTI(t=-3.180，P=0.002)更低。二元Logistic回归结果显示高血糖(OR=1.409,95%CI：1.245～1.593，P＜0.001)、血碱性磷酸酶升高(OR=1.010,95%CI：1.001～1.019，P=0.034)和LTI减少(OR=0.809,95%CI：0.659～0.993，P=0.042)是MHD患者发生透析前慢性低钠血症的危险因素。结论透析前慢性低钠血症在MHD患者中普遍存在。高血糖、血碱性磷酸酶升高和营养不良是发生透析前慢性低钠血症的危险因素。
Objective To explore the risk factors of pre-dialysis chronic hyponatremia in maintenance hemodialysis (MHD) patients. Methods We retrospectively analyzed the 152 MHD patients treated in the Blood Purification Center of Peking University International Hospital from August 2017 to June 2020. Their blood sodium, glucose, albumin, alkaline phosphatase, and other laboratory results were measured before dialysis every 1-3 months, and the time-averaged values including time-averaged serum sodium (TASNa) were calculated. Bioimpedance analysis (BIA) was also measured every 1-3 months, and the indexes including overhydration (OH), extracellular water, intracellular water (ICW), and lean tissue index (LTI) were recorded. The patients were then divided into two groups based on the TASNa, hyponatremia (TASNa≤135mmol/L) and normonatremia (135＜ TASNa ＜145 mmol /L). The differences between the two groups were compared by independent sample t-test or chi square test, and the risk factors for pre-dialysis chronic hyponatremia were analyzed by binary logistic regression. Results The prevalence of hyponatremia based on TASNa was 23.7%, and the prevalence of hyponatremia adjusted by blood glucose was 9.9%. Compared with the normonatremia group, the hyponatremia group had a higher proportion of diabetes (c2=27.134, P＜0.001), and higher levels of clinic systolic blood pressure (t=2.175, P=0.031), blood glucose (t=6.408, P＜0.001) and OH (t=2.930, P=0.004) in the hyponatremia group, while serum creatinine (t=-4.008, P＜0.001), blood urea nitrogen(t=-2.169, P=0.032), chloride (t=-7.898, P＜0.001), prealbumin (t=-3.692, P＜0.001), albumin (t=-2.170, P=0.032), phosphorus (t=-2.476, P=0.014), uric acid (t=-2.168, P=0.032), effective plasma osmolality (t= -3.737, P=0.001), ICW (t=-2.113, P=0.038) and LTI (t=-3.180, P=0.002) were lower in the hyponatremia group. Binary logistic regression showed that hyperglycemia (OR=1.409, 95% CI: 1.245～1.593, P＜0.001), elevated serum alkaline phosphatase (OR=1.010, 95% CI: 1.001～1.019, P=0.034) and decreased LTI (OR=0.809, 95% CI: 0.659-0.993, P=0.042) were the risk factors for pre-dialysis chronic hyponatremia in MHD patients. Conclusion pre-dialysis chronic hyponatremia is common in MHD patients. Hyperglycemia, elevated serum alkaline phosphatase and malnutrition are the risk factors for pre-dialysis chronic hyponatremia.
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