目的 探讨腹膜透析(peritoneal dialysis,PD)患者营养状况变化与睡眠障碍及瘙痒的关系。 方法 使用匹兹堡睡眠质量指数(pittsburgh sleep quality index，PSQI)问卷及中文版四项目瘙痒问卷(four-item itch questionnaire,FIIQ)对西安交通大学第一附属医院肾脏内科腹膜透析中心规律随访超过3个月的PD患者进行睡眠质量及瘙痒评分，收集患者临床资料、透析充分性，透析前白蛋白(ALB0)和研究时白蛋白(ALB1)及其他生化指标。根据白蛋白水平变化，将所有患者分为A组：白蛋白正常组(ALB0，ALB1均≥35g/L)，B组：白蛋白升高组(ALB0＜35g/L，ALB1≥35g/L)，C组：持续低白蛋白组(ALB0，ALB1均＜35g/L),D组：白蛋白降低组(ALB0≥35g/L，ALB1＜35g/L),分析血清白蛋白变化对睡眠及瘙痒的影响。 结果 ①共调查166人，其中A组63人，B组47人，C组38人，D组18人。4组年龄(F =8.490， P ＜0.001)，透析龄(F =2.266，P =0.043)，C反应蛋白(F =4.051，P =0.025)，糖尿病比例(χ2=28.160， P ＜0.001)比较差异有统计学意义。②PSQI睡眠评分D组高于A组(H =9.037，P =0.022)及B组(H =6.806，P =0.033)，C组高于A组(H =3.269，P =0.049)及B组(H=3.503，P =0.045)，与D组比较无统计学差异(H =23.458，P =0.459)。FIIQ瘙痒评分D组高于A组(P =0.001)，B组(P =0.003),C组(P =0.006)。睡眠障碍发生率，D组为55.6%,高于其他3组(与其他3组比较，均P ＜0.05)；瘙痒发生率D组为64.7%，高于其他3组(与其他3组两两比较，均P ＜0.05)。③Logistics回归示：透析后白蛋白降低是瘙痒(OR=3.886，95% CI：1.132～13.333,P =0.031)、睡眠障碍(OR =4.682,95% CI：1.466～14.958，P =0.009)的独立危险因素。 结论 ①糖尿病、老年、透析龄长、微炎症状态的PD患者，更容易出现营养不良及营养状态恶化。②PD患者营养恶化使睡眠障碍及瘙痒风险增加。
Objective To investigate the influence of serum albumin changes on sleep quality and uremic pruritus in peritoneal dialysis (PD) patients. Methods Pittsburgh Sleep Quality Index (PSQI) and Four-Item Itch Questionnaire (FIIQ) were used to assess sleep quality and pruritus in the 166 PD patients regularly followed up in our PD center. Their clinical data and laboratory results were recruited. According to the changes of serum albumin level before PD (ALB0) and after PD (ALB1), the PD patients were divided into four groups: group A, normal albumin group (both ALB0 and ALB1 ≥35g/L); group B, elevated albumin group (ALB0＜35g/L, and ALB1≥35g/L); group C, persistent low protein group (both ALB0 and ALB1＜35g/L); group D, decreased albumin group (ALB0≥35g/L, and ALB1＜35g/L). Sleep disturbance, itching and other clinical parameters were compared among the groups. Results ①There were 63 patients in group A, 47 in group B, 38 in group C, and 18 in group D. Age (F=8.490, P＜0.001), dialysis duration (F=2.266, P=0.043), CRP (F=4.051, P=0.025) and the incidence of diabetes (χ²=28.160, P＜0.001) were significantly different among the four groups. ②The mean PSQI sleep score in group D was higher than that in group A (H=9.037, P=0.022) and group B (H=6.806, P=0.033); the mean PSQI sleep score in group C was higher than that in group A (H=3.269, P=0.049) and group B (H=3.503, P=0.045); the mean PSQI sleep score had no difference between group D and group C (H=23.458, P=0.459). The pruritus score in group D was significantly higher than that in groups A, B and C (P=0.001, 0.003 and 0.006 respectively). The incidence of sleep disorder in group D was 55.6%, significantly higher than that in groups A, B and C (P ＜0.05). The incidence of pruritus in group D was 64.7%, also significantly higher than that in groups A, B and C (P＜0.05). ③Logistic regression showed that decreased serum albumin after PD was an independent risk factor for pruritus (OR=3.886, 95% CI :1.132～13.333, P=0.031) and sleep disorder (OR=4.682, 95% CI 1.466～14.958, P=0.009). Conclusion ①PD patients with diabetes, older age, longer dialysis duration and micro-inflammatory state are prone to suffer from malnutrition or to negatively affect the nutritional status. ②Deterioration of nutritional status leads to the risk of sleep disorders and pruritus in PD patients.
[] 范汝艳，张红梅，常立阳.太极拳运动对血液透析患者焦虑抑郁状态和睡眠质量的影响［J］.中国血液净化，2016,15(4):241- 243．
[] Li Jin，Xiaopei Wang, Ying Ma et al.Serum albumin at 1 year after peritoneal dialysis predicts long-term outcomes on continuous ambulatory peritoneal dialysis[J].Renal Failure,2022, 44 :1, 252–257
[] 刘贤臣，唐茂芹，胡蕾，等．匹兹堡睡眠质量指数的信度和效度研究[J]．中华精神科杂志，1996，29(2):103-107．
[] Gunthert AR, Duclos K, Jahns BG, et al. Clinical scoring system for vulvar lichen sclerosus[J]. Journal of Sexual Med. 2012;9:2342–50.
[] 吕晶,汪涛,尹爱平.临终腹膜透析患者姑息治疗的回顾性分析[J].中国康复医学杂志, 2005,03: 208-210.
[] De Mutsert R, Grootendorst DC, Axelsson J, et al; NECOSAD Study Group. Excess mortality due to interaction between protein-energy wasting, inflammation and cardiovascular disease in chronic dialysis patients[J]. Nephrol Dial Transplant.2008，23:2957- 2964
[] Takahashi H, Ito Y, Ishii H, et al. Geriatric nutritional risk index accurately predicts cardiovascular mortality in incident hemodialysis patients[J]. J Cardiol 2014，64:32-36,
[] Li, Han，Li, Xiaobei，Feng, Sujuan，et al.Sleep disorders and its related risk factors in patients undergoing chronic peritoneal dialysis[J].Chin Med J （Engl）.2014;127(7):1289-1293.
[] Razeghi E, Sahraian MA, Heidari R, et al. Association of inflammatory biomarkers with sleep disorders in hemodialysis patients[J]. Acta Neurol Belg 2012;112:45e9.
[] Dukkipati, R. & Kopple, J. D. Causes and prevention of protein-energy wasting in chronic kidney failure[J]. Semin. Nephrol.2009,29：39–49.
[] Pisoni RL, Wikstr?m B, Elder SJ, et al. Pruritus in haemodialysis patients: International results from the Dialysis Outcomes and Practice Patterns Study (DOPPS)[J]. Nephrol Dial Transplant. 2006 Dec;21(12):3495–505.
[] Min JW, Kim SH, Kim YO, et al. Comparison of uremic pruritus between patients undergoing hemodialysis and peritoneal dialysis[J]. Kidney Res Clin Pract. 2016;35(2):107–13
[] Arzhan S，Roumelioti ME，Unruh ML.Itch and Ache on Dialysis: New Approaches to Manage Uremic Pruritus and Restless Legs[J].Blood Purif.2020;49(1-2):222-227.doi：10.1159/000504081
[] Badiee Aval S, Ravanshad Y, Azarfar A, et al. A Systematic Review and Meta-analysis of Using Acupuncture and Acupressure for Uremic Pruritus[J]. Iran J Kidney Dis. 2018;12(2): 78–83.
[] 何玉婷,门春翠,牛庆雨,芦丽霞,乔婕,邵琳,武向兰,武蓓,赵慧萍,左力,王梅. 维持性腹膜透析患者皮肤瘙痒的发生情况和影响因素分析[J]. 中国血液净化,2019,18(09):653-657.
[] Min JW, Kim SH, Kim YO, et al. Comparison of uremic pruritus between patients undergoing hemodialysis and peritoneal dialysis[J]. Kidney Res Clin Pract. 2016;35(2):107–13.
[] 司博林,程慧栋,华琴,李婧. 费瑞卡对腹膜透析患者肠道菌群和营养状况的调节作用[J]. 中国中西医结合肾病杂志,2021,22(06):531-533.
