目的 分析接受不同透析方式的终末期肾病患者发生认知障碍(cognitive impairment，CI)的危险因素。 方法 选取2021年11月～2022年4月在蚌埠医学院第一附属医院规律行维持性血液透析(maintenance hemodialysis，MHD)患者93例，腹膜透析(peritoneal dialysis，PD)患者50例。根据《蒙特利尔认知评估量表》评估得分，将患者分为MHD患者CI组、MHD患者无CI组、PD患者CI组、PD患者无CI组，分析其间CI的相关危险因素。 结果 本研究共入组143例患者，男性70例(48.95%)，年龄(52.25±11.37)岁，合并CI75例，患病率为52.45%。多因素Logistic回归分析显示年龄、血小板/淋巴细胞比值(PLR)、胱抑素C、血清同型半胱氨酸(Hcy)是MHD患者发生CI的独立危险因素(OR值分别为1.080、1.017、1.749、1.167，95%CI分别为1.001～1.166、1.003～1.030、1.205～2.541、1.003～1.358， P值分别为0.047、0.013、0.003、0.046)；而年龄、血红蛋白、PLR、25羟-维生素-D是PD患者发生CI的独立危险因素(OR值分别为1.253、0.907、1.027、0.696，95%CI分别为1.042～1.507、0.830～0.992、1.001～1.054、0.491～0.989，P值分别为0.016、0.032、0.044、0.043)。受试者工作特征曲线分析提示年龄、PLR以及两者联合模型对MHD及PD患者发生认知功能障碍均有较好的预测效能，其中联合模型预测效能最高(MHD患者中AUC分别为0.714、0.723、0.798，95% CI分别为0.611～0.817、0.620～0.826、0.711～0.886，P值均P＜0.001；PD患者中AUC分别为0.684、0.810、0.849，95%CI分别为0.533～0.836、0.679～0.941、0.736～0.962，P值分别为0.027、＜0.001、＜0.001)。 结论 MHD患者中年龄、PLR、胱抑素C、Hcy是发生CI的独立危险因素，PD患者中年龄、PLR、血红蛋白、25羟-维生素-D是发生CI的独立危险因素，在临床治疗过程中应密切关注上述因素，早期实施干预措施，进而延缓或者避免患者发生认知功能障碍。
Objective To analyze the risk factors of cognitive impairment (CI) in patients with end-stage renal disease and receiving different dialysis methods. Methods A total of 93 patients on maintenance hemodialysis (MHD) and 50 patients on peritoneal dialysis (PD) treated in the First Affiliated Hospital of Bengbu Medical College from November 2021 to April 2022 were recruited as the research subjects. According to the scores of Montreal cognitive assessment, the patients were divided into CI group of MHD patients, non-CI group of MHD patients, CI group of PD patients, and non-CI group of PD patients. CI and related risk factors was analyzed between the groups. Results A total of 143 patients were enrolled in this study, 70 (48.95%) were males, and the mean age was 52.25±11.37 years old. A total of 75 patients had CI, with a prevalence rate of 52.45%. Multivariate logistic regression showed that age, platelet/lymphocyte ratio (PLR), cystatin C, and homocysteine (Hcy) were the independent risk factors for CI in MHD patients (OR=1.080, 1.017, 1.749 and 1.167 respectively; 95% CI：1.001～1.166, 1.003～1.030, 1.205～2.541 and 1.003～1.358 respectively; P=0.047, 0.013, 0.003 and 0.046 respectively); while age, hemoglobin, PLR, and 25-hydroxy-vitamin-D were the independent risk factors for CI in PD patients (OR=1.253, 0.907, 1.027 and 0.696 respectively; 95% CI：1.042～1.507, 0.830～0.992, 1.001～1.054 and 0.491～0.989 respectively; P= 0.016, 0.032, 0.044 and 0.043 respectively). Receiver operating characteristic curve analysis showed that age, PLR and the model of the combined two had better predictive values for CI in MHD and PD patients, and the combined model had the highest predictive value (for MHD patients: AUC=0.714, 0.723 and 0.798 respectively; 95% CI：0.611～0.817, 0.620～0.826 and 0.711～0.886 respectively; P＜0.001; for PD patients: AUC=0.684, 0.810 and 0.849 respectively; 95% CI：0.533～0.836, 0.679～0.941 and 0.736～0.962 respectively; P=0.027, ＜0.001 and ＜0.001 respectively). Conclusion Age, PLR, cystatin C and Hcy are the independent risk factors for CI in MHD patients; age, PLR, hemoglobin and 25-hydroxy-vitamin-D are the independent risk factors for CI in PD patients. Therefore, these factors should be closely monitored during treatment of MHD and PD patients. Early intervention of these factors may delay or avoid the occurrence of CI in dialysis patients.
[1]GBD Chronic Kidney Disease Collaboration.Global, regional, and national burden of chronic kidney disease, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017[J]. Lancet, 2020 Feb 29; 395(10225):709-733.
[2]Drew DA, Weiner DE, Sarnak MJ.Cognitive Impairment in CKD: Pathophysiology, Management, and Prevention[J]. Am J Kidney Dis, 2019 Dec; 74(6):782-790.
[3]Shea YF, Lam MF, Lee MS, et al.Prevalence of Cognitive Impairment Among Peritoneal Dialysis Patients, Impact on Peritonitis and Role of Assisted Dialysis[J]. Perit Dial Int, 2016 May-Jun; 36(3):284-90.
[4]Angermann S, Schier J, Baumann M, et al.Cognitive Impairment is Associated with Mortality in Hemodialysis Patients[J]. J Alzheimers Dis, 2018; 66(4):1529-1537.
[5]Viggiano D, Wagner CA, Martino G, et al.Mechanisms of cognitive dysfunction in CKD[J]. Nat Rev Nephrol, 2020 Aug; 16(8):452-469.
[6]Drew DA, Tighiouart H, Rollins J, et al.Evaluation of Screening Tests for Cognitive Impairment in Patients Receiving Maintenance Hemodialysis[J]. J Am Soc Nephrol, 2020 Apr; 31(4):855-864.
[7]Shea YF, Lee MC, Mok MM, et al.Prevalence of cognitive impairment among peritoneal dialysis patients: a systematic review and meta-analysis[J]. Clin Exp Nephrol, 2019 Oct; 23(10):1221-1234.
[8]Pei X, Lai S, He X, et al.Mild cognitive impairment in maintenance hemodialysis patients: a cross-sectional survey and cohort study[J]. Clin Interv Aging, 2018 Dec 20; 14:27-32.
[9]Drew DA, Weiner DE, Tighiouart H, et al.Cognitive Decline and Its Risk Factors in Prevalent Hemodialysis Patients[J]. Am J Kidney Dis, 2017 Jun; 69(6):780-787.
[10]Ebert T, Neytchev O, Witasp A, et al.Inflammation and Oxidative Stress in Chronic Kidney Disease and Dialysis Patients[J]. Antioxid Redox Signal, 2021 Dec 10; 35(17):1426-1448
[11]Shen XN, Niu LD, Wang YJ, et al.Inflammatory markers in Alzheimer' s disease and mild cognitive impairment: a meta-analysis and systematic review of 170 studies[J]. J Neurol Neurosurg Psychiatry, 2019 May; 90(5):590-598.
[12]Shen J, Amari N, Zack R, et al.Plasma MIA, CRP, and albumin predict cognitive decline in Parkinson' s Disease[J]. Ann Neurol, 2022 May 20
[13]Li P, Xia C, Liu P, et al.Neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio in evaluation of inflammation in non-dialysis patients with end-stage renal disease (ESRD) [J]. BMC Nephrol, 2020 Nov 25; 21(1):511.
[14]税灵, 达静静, 何平红, 等.血小板淋巴细胞比值与糖尿病合并维持性血液透析患者认知功能障碍的相关性[J].中华医学杂志, 2021, 101(10):722-726
[15]Shaker AM, Mohamed OM, Mohamed MF, et al.Impact of correction of anemia in end-stage renal disease patients on cerebral circulation and cognitive functions[J]. Saudi J Kidney Dis Transpl, 2018 Nov-Dec; 29(6):1333-1341.
[16]Zheng G, Wen J, Lu H, et al.Elevated global cerebral blood flow, oxygen extraction fraction and unchanged metabolic rate of oxygen in young adults with end-stage renal disease: an MRI study[J]. Eur Radiol, 2016 Jun; 26(6):1732-41.
[17]Reza-Zaldívar EE, Sandoval-Avila S, Gutiérrez-Mercado YK, et al.Human recombinant erythropoietin reduces sensorimotor dysfunction and cognitive impairment in rat models of chronic kidney disease[J]. Neurologia (Engl Ed), 2020 Apr; 35(3):147-154. English, Spanish.
[18]Wanggong F, Xiang J, Yang S, et al.Correlation of serum uric acid, cystatin C and high-sensitivity C-reactive protein with cognitive impairment in lacunar cerebral infarction[J]. Am J Transl Res, 2021 Jun 15; 13(6):6717-6723.
[19]Feng J, Lu X, Wang S, et al.The assessment of cognitive impairment in maintenance hemodialysis patients and the relationship between cognitive impairment and depressive symptoms[J]. Semin Dial, 2021 Nov 2.
[20]温莉玲, 梁春波.高通量血液透析对慢性肾功能衰竭尿毒症患者血清因子及近期预后影响[J].临床军医杂志, 2019, 47(04):354-356
[21]张烨, 汪聪, 严良烽, 等.高通量血液透析对同型半胱氨酸及型末端脑利钠肽前体的影响[J].中国当代医药, 2019, 26(19):97-99
[22]Lee EY, Lee SJ, Kim KM, et al.Association of metabolic syndrome and 25-hydroxyvitamin?D with cognitive impairment among elderly Koreans[J]. Geriatr Gerontol Int, 2017 Jul; 17(7):1069-1075.
[23] Zhang C, Wang J, Xie X, et al.Low serum vitamin D concentration is correlated with anemia, microinflammation, and oxidative stress in patients with peritoneal dialysis[J]. J Transl Med, 2021 Sep 27; 19(1):411.
