目的 探讨维持性血液透析(maintenance hemodialysis patients，MHD)患者肌少症与同型半胱氨酸(homocysteinemia，Hcy)、鸢尾素(Irisin)及营养不良-炎症评分(malnutrition-inflammation score，MIS)的相关性。 方法 选取2019年6月～2021年10月在济南市第八人民医院血液净化中心的MHD患者206例为研究对象，通过握力、步行速度、四肢骨骼肌质量指数诊断肌少症，采用酶联免疫吸附法检测患者血清Hcy、Irisin水平，应用MIS量表进行营养不良-炎症评估。根据多因素Logistic回归结果建立列线图模型。 结果 在206例被研究对象中，56例(27.2％)患有肌少症。多因素Logstic回归分析结果显示：透析龄、合并认知功能障碍、Hcy、MIS评分是影响MHD患者发生肌少症的独立危险因素(OR值分别为1.423，1.718，1.728，2.104，95%CI：值分别为1.111～1.820，1.222～2.223，1.348～2.446，1.424～3.442，P值分别为0.038，0.021，0.026，＜0.001)，Irisin是MHD患者发生肌少症的独立保护因素(OR=0.488，95% CI：0.089～0.762，P＜0.001)。据此构建的列线图预测模型采用Bootstrap内部验证，发现该模型具有良好的精准度和区分度，C-index指数为0.822(95%CI：为0.734～0.887)。 结论 MIS评分、Hcy水平升高是MHD患者发生肌少症的独立危险因素，Irisin水平升高是MHD患者发生肌少症的独立保护因素，基于独立影响因素建立的列线图预测模型能够提高对MHD患者并发肌少症的预测效能。
Objective To explore the correlation between sarcopenia and the levels of homocysteine (Hcy), irisin and malnutrition-inflammation score (MIS) in maintenance hemodialysis (MHD) patients. Methods A total of 206 MHD patients treated in the Blood Purification Center of Jinan Eighth People’s Hospital from June 2019 to October 2021 were selected as the research subjects. Sarcopenia was diagnosed by handgrip strength, walking speed, and limb skeletal muscle mass index (ASMI). Serum levels of Hcy and irisin were measured by enzyme-linked immunosorbent assay. Nutrition-inflammation was assessed using the MIS scale. A nomogram model was constructed based on the multivariate logistic regression results. Results Among the 206 MHD patients, 56 (27.2％) were diagnosed with sarcopenia. Logistic regression showed that dialysis age, combined cognitive dysfunction, Hcy and MIS were the independent risk factors for the development of sarcopenia in MHD patients (OR=1.423, 1.718, 1.728 and 2.104 respectively; 95% CI :1.111~1.820, 1.222~2.223, 1.348~2.446 and 1.424~3.442 respectively; P=0.038, 0.021, 0.026 and＜0.001 respectively). Irisin was an independent protective factor for sarcopenia in MHD patients (OR=0.488, 95% CI :0.089~0.762, P＜0.001). The prediction nomogram model constructed based on the above analyses and using Bootstrap internal verification indicates that this model has good accuracy and discrimination, with the C-index index of 0.822 (95% CI :0.734~0.887). Conclusion Higher MIS and elevated serum Hcy were the independent risk factors for sarcopenia in MHD patients. Elevated serum irisin was an independent protective factor for sarcopenia in MHD patients. The prediction nomogram model based on the independent influencing factors is useful to improve the predictive ability of sarcopenia complicated in MHD patients.
[1] Cruz-Jentoft A J, Sayer A A. Sarcopenia[J]. Lancet, 2019, 393(10191): 2636-2646.
[2] Veeranki S, Lominadze D, Tyagi S C. Hyperhomocysteinemia inhibits satellite cell regenerative capacity through p38 alpha/beta MAPK signaling[J]. Am J Physiol Heart Circ Physiol, 2015, 309(2): H325-34.
[3] Reza M M, Subramaniyam N, Sim C M, et al. Irisin is a pro-myogenic factor that induces skeletal muscle hypertrophy and rescues denervation-induced atrophy[J]. Nat Commun, 2017, 8(1): 1104.
[4] Kalantar-Zadeh K, Kopple J D, Humphreys M H, et al. Comparing outcome predictability of markers of malnutrition-inflammation complex syndrome in haemodialysis patients[J]. Nephrol Dial Transplant, 2004, 19(6): 1507-19.
[5] 姜珊, 康琳, 刘晓红. 2019亚洲肌少症诊断及治疗共识解读[J]. 中华老年医学杂志, 2020, 39(4): 373-376.
[6] Jagadeswaran D, Indhumathi E, Hemamalini A J, et al. Inflammation and nutritional status assessment by malnutrition inflammation score and its outcome in pre-dialysis chronic kidney disease patients[J]. Clin Nutr, 2019, 38(1): 341-347.
[7] Chen L K, Woo J, Assantachai P, et al. Asian Working Group for Sarcopenia: 2019 Consensus Update on Sarcopenia Diagnosis and Treatment[J]. J Am Med Dir Assoc, 2020, 21(3): 300-307.e2.
[8] Lamarca F, Carrero J J, Rodrigues J C, et al. Prevalence of sarcopenia in elderly maintenance hemodialysis patients: the impact of different diagnostic criteria[J]. J Nutr Health Aging, 2014, 18(7): 710-7.
[9] Umakanthan M, Li J W, Sud K, et al. Prevalence and Factors Associated with Sarcopenia in Patients on Maintenance Dialysis in Australia-A Single Centre, Cross-Sectional Study[J]. Nutrients, 2021, 13(9).
[10] Giglio J, Kamimura M A, Lamarca F, et al. Association of Sarcopenia With Nutritional Parameters, Quality of Life, Hospitalization, and Mortality Rates of Elderly Patients on Hemodialysis[J]. J Ren Nutr, 2018, 28(3): 197-207.
[11] Gurlek Demirci B, Carrero J J, Tutal E, et al. Effect of nutritional support on nutritional status and inflammation in malnourished patients undergoing maintenance hemodialysis[J]. Hemodial Int, 2021, 25(4): 532-540.
[12] Santos C P, Silva L F, Lopes M B, et al. Associations of physical activity energy expenditure with nutritional-inflammatory markers in hemodialysis patients[J]. Int J Artif Organs, 2017, 40(12): 670-675.
[13] Qiao X, Nie Y, Ma Y, et al. Irisin promotes osteoblast proliferation and differentiation via activating the MAP kinase signaling pathways[J]. Sci Rep, 2016, 6: 18732.
[14] 田梦婷, 刘晶, 曾雪敏, et al. 鸢尾素对大鼠骨髓间充质干细胞Sost基因表达及成骨分化的影响[J]. 中华口腔医学研究杂志（电子版）, 2019, 13(3): 144-150.
[15] 王亚美, 刘风勋, 邢利, et al. Irisin与维持性血液透析患者肌肉减少症的相关性研究[J]. 中国血液净化, 2019, 18(10): 677-680.
[16] 邵雯, 李荣山, 周晓霜. 维持性血液透析合并肌少症患者血清鸢尾素的变化[J]. 华西医学, 2020, 35(7): 788-793.
[17] Badri S, Vahdat S, Seirafian S, et al. Homocysteine-Lowering Interventions in Chronic Kidney Disease[J]. J Res Pharm Pract, 2021, 10(3): 114-124.
[18] 陆冰, 刘晔, 陈吉海, et al. 住院老年患者血浆同型半胱氨酸水平与肌少症的相关性研究[J]. 中华全科医学, 2021, 19(11): 1819-1822.
[19] Angermann S, Baumann M, Wassertheurer S, et al. Pulse wave velocity is associated with cognitive impairment in hemodialysis patients[J]. Clin Sci (Lond), 2017, 131(13): 1483-1493.
[20] Smith A D, Refsum H, Bottiglieri T, et al. Homocysteine and Dementia: An International Consensus Statement[J]. J Alzheimers Dis, 2018, 62(2): 561-570.
