目的 观察透析间期体质量增长(interdialytic weight gain，IDWG)变异度对维持性血液透析(maintenance hemodialysis，MHD)患者预后的影响。方法 收集2018年10月～2021年10月复旦大学附属闵行医院肾内科229位MHD患者一般情况、实验室指标及患者转归资料。根据透析间期体质量增长变异度(interdialytic weight gain coefficient of variation,IDWG-CV)三分位数.374(0.287，0.410)，将患者分为IDWG高变异组、IDWG中变异组和IDWG低变异组3组。分析IDWG-CV与全因死亡、心血管事件死亡之间的关系。结果 229例患者平均年龄(61.79±14.47)岁，平均透析龄(58.93±21.10)月，死亡患者55例(24%)，其中心血管事件死亡24例(10.5%)。IDWG-CV高变异组心血管事件死亡率高于IDWG-CV中变异组和IDWG-CV低变异组(χ2=8.724，P=0.013), 全因死亡率高于IDWG-CV中变异组和IDWGCV低变异组，但无统计学意义(χ2=5.219，P=0.074)。结合IDWG是否达标的亚组分析显示，IDWG未达标且高变异组的全因死亡分别高于其他 5 组(χ2=22.351、2.030、11.379、0.765、11.831，P＜0.001、0.154、0.001、0.382、0.001)心血管死亡较其他5组相比最高(χ2=11.672、7.506、10.201、1.851、7.305，P=0.001、0.006、0.001、0.174、0.007)。COX 回归分析显示，高龄(HR=2.365,95% CI：1.160～4.822,P=0.018)、少尿(HR=0.525,95%CI：0.284～0.972,P=0.040)、低蛋白血症(HR=0.291,95% CI：0.162～0.522,P＜0.001)和高IDWG(HR=3.385,95% CI：1.909～6.002,P＜0.001)是MHD患者全因死亡的独立危险因素；低蛋白血症(HR=0.223,95% CI：0.087～0.575,P=0.002)和高 IDWG(HR=3.318,95% CI：1.387～7.940,P=0.007)是MHD患者心血管死亡的独立危险因素。Kaplan-Meier生存分析显示，IDWG未达标的全因死亡和心血管死亡患者的累积生存率均低于达标的患者(χ2=26.570、10.423，P＜0.001、0.001)；IDWG高变异的全因死亡和心血管死亡患者的累积生存率低于低变异组和中变异组的患者(χ2=7.116、10.097，P=0.028、0.006)。 结论 MHD患者IDWG变异度较大的患者全因死亡和心血管事件死亡风险高，其中IDWG不达标且变异度大的患者死亡率更高。控制IDWG达标且低变异度可能更有益于提高MHD患者生存率。
Objective To observe the influence of interdialytic weight gain (IDWG) variation on prognosis in maintenance hemodialysis (MHD) patients. Methods The general information, laboratory indicators and patient outcomes of 229 MHD patients during October 2018 to October 2021 were recruited from the Department of Nephrology, Minhang Hospital, Fudan University. According to the interdialytic weight gain coefficient of variation (IDWG-CV), patients were divided into three groups: high IDWG variation group (IDWG-CV average of 0.617), moderate IDWG variation group (IDWG-CV average of 0.345) and low IDWG variation group (IDWG-CV average of 0.231). The relationship between IDWG-CV and all-cause mortality and cardiovascular disease mortality was analyzed. Results In the 229 MHD patients, the mean age was 61.79±14.47 years, the mean age of dialysis was 58.93±21.10 months (95% CI: 56.187～61.682), and 55 patients (24%) died, among which 24 patients (10.5%) died of cardiovascular diseases. The all-cause mortality
in the high IDWG variation group was higher than that in the moderate and low IDWG variation groups but without statistical significance (31.6% vs. 24.7% vs. 15.8%, χ2=5.219, P=0.074). The cardiovascular disease mortality in the high IDWG variation group was also higher than that in the moderate and low IDWG variation groups (18.4% vs. 9.1% vs. 3.9%, χ2=8.724, P=0.013). Subgroup of the patients based on whether IDWG variation of the patient was in the target range showed that all-cause mortality and cardiovascular disease mortality were higher in the patients with higher IDWG variation out of the target range than in the patients in other 5 groups (For all- cause mortality: 51.4% vs. 14.6%, 40.0%, 17.3%, 33.3% and 6.1%; χ2=22.351, 2.030,
11.379, 0.765 and 11.831; P＜0.001, 0.154, 0.001, 0.382 and 0.001. For cardiovascular disease mortality: 31.4% vs. 7.3%, 16.0%, 5.8%, 3.7% and 4.1%; χ2=11.672, 7.506, 10.201, 1.851 and 7.305; P=0.001, 0.006, 0.001, 0.174 and 0.007). COX regression showed that advanced age (HR=2.365, 95% CI: 1.160～4.822, P=0.018), oliguria (HR=0.525, 95% CI: 0.284～0.972, P=0.040), hypoproteinemia (HR=0.291, 95% CI: 0.162～0.522, P＜0.001) and higher IDWG (HR=3.385, 95% CI: 1.909～6.002, P＜0.001) were the independent risk factors for all- cause mortality in MHD patients; hypoproteinemia (HR=0.223, 95% CI: 0.087～ 0.575, P=0.002) and higher IDWG (HR=3.318, 95% CI: 1.387～7.940, P=0.007) were the independent risk
factors for cardiovascular disease mortality in MHD patients. Kaplan-Meier survival analysis showed that the patients with IDWG variation not in the target range had higher all-cause mortality and cardiovascular disease mortality than those with IDWG variation in the target range (χ2=26.570 and 10.423, P＜0.001 and 0.001). The patients with higher IDWG variation had higher all-cause mortality and cardiovascular disease mortality than those with moderate and low IDWG variation (χ2=7.116 and 10.097, P=0.028 and 0.006). Conclusions MHD patients with higher IDWG variation have higher all-cause mortality and cardiovascular disease mortality. Patients with higher IDWG variation out of the target range have a higher mortality. Control of the IDWG variation within the target range and with low IDWG variation may be beneficial in improving survival rate in MHD patients.
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