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中华肾病研究电子杂志

中华肾病研究电子杂志 ›› 2019, Vol. 08 ›› Issue (04) : 163 -169. doi: 10.3877/cma.j.issn.2095-3216.2019.04.005

所属专题： 文献；

论著

单次人体成分分析参数对住院尿毒症透析患者的预后价值
严陈燕1, 邬步云2, 王雅杰2, 徐琳2, 许雪强2, 张承宁2, 黄智敏2, 任海滨2, 吴晶晶2, 毛慧娟2,†(), 邢昌赢2   
  1. 1. 211100　南京市江宁医院肾内科
    2. 210029　南京医科大学第一附属医院（江苏省人民医院）肾内科
  • 收稿日期:2018-12-02 出版日期:2019-08-28
  • 通信作者: 毛慧娟
  • 基金资助:
    江苏省教育厅六大人才高峰(WSN-056); 江苏省青年医学人才(QNRC2016576); 2017年江苏省卫生和健康委员会科研项目(H2017023)

Prognostic value of single-measure of body composition analysis parameters in hospitalized uremic patients undergoing dialysis

Chenyan Yan1, Buyun Wu2, Yajie Wang2, Lin Xu2, Xueqiang Xu2, Chengning Zhang2, Zhimin Huang2, Haibin Ren2, Jingjing Wu2, Huijuan Mao2,†(), Changying Xing2   

  1. 1. Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University (Jiangsu Province Hospital), Nanjing 210029, Jiangsu Province, China; Department of Nephrology, Nanjing Jiangning Hospital, Nanjing 211100; Jiangsu Province, China
    2. Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University (Jiangsu Province Hospital), Nanjing 210029, Jiangsu Province, China
  • Received:2018-12-02 Published:2019-08-28
  • Corresponding author: Huijuan Mao
  • About author:
    Corresponding author: Mao Huijuan, Email:
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引用本文：

严陈燕, 邬步云, 王雅杰, 徐琳, 许雪强, 张承宁, 黄智敏, 任海滨, 吴晶晶, 毛慧娟, 邢昌赢. 单次人体成分分析参数对住院尿毒症透析患者的预后价值[J/OL]. 中华肾病研究电子杂志, 2019, 08(04): 163-169.

Chenyan Yan, Buyun Wu, Yajie Wang, Lin Xu, Xueqiang Xu, Chengning Zhang, Zhimin Huang, Haibin Ren, Jingjing Wu, Huijuan Mao, Changying Xing. Prognostic value of single-measure of body composition analysis parameters in hospitalized uremic patients undergoing dialysis[J/OL]. Chinese Journal of Kidney Disease Investigation(Electronic Edition), 2019, 08(04): 163-169.

目的

探讨生物电阻抗单次测定的营养及液体负荷指标对住院尿毒症患者预后的预测价值。

方法

前瞻性连续纳入2014年1月至2016年12月在南京医科大学第一附属医院肾内科住院的成年维持性透析患者(包括血液透析、腹膜透析患者)，患者入院后前3 d内均使用人体成分检测仪测定透析前人体成分。使用Kaplan-Meier法绘制生存曲线，使用Cox回归分析瘦体重指数(LTI)、脂肪组织指数(FTI)、细胞外液(ECW)与体细胞质量(BCM)比值(ECW/BCM)、过多水负荷(OH)与预后的关系，并进行多因素校正Cox回归分析。

结果

(1)排除失访患者12例及随访期间行肾移植患者20例后共纳入819例患者，其中血液透析患者696例，腹膜透析患者123例。平均随访时间(28.1±9.7)月，172例(21%)患者随访期间死亡。(2)按照OH<-1L、-1～1 L及>1L将患者分为3组、按照OH/ECW比值将患者分为液体负荷过量(fluid overload)和液体平衡(fluid balance)两组、按照LTI、FTI、ECW/BCM的四分位数将患者各分为4组。生存分析发现不同OH组患者的死亡无显著差异(χ2＝ 2.4767，P＝0.2899)，而不同体液状态的两组患者、不同LTI、FTI、ECW/BCM的4组患者的死亡有显著差异(体液状况2个组比较，χ2＝12.3874, P＝0.0004；LTI 4个组比较，χ2＝ 57.0897，P<0.0001；FTI 4个组比较，χ2 ＝ 10.5650, P＝0.0143；ECW/BCM 4个组比较，χ2＝69.5081，P<0.0001)。其中，液体负荷组、LTI越低组，FTI越高组，ECW/BCM越高组，死亡风险趋向增高。多因素COX回归显示在校正透析龄、糖尿病、感染、舒张压、FTI、ECW/BCM后，高龄、高Charlson评分、低白蛋白、低LTI均是透析患者死亡的独立危险因素(HRage＝1.03, P<0.001; HRCharlson＝1.18, P＝0.003; HRAlb＝0.94, P<0.001; HRLTI＝0.84, P<0.001)。(3)按Alb和LTI的中位数将人群分为4组，发现预后按以下分组顺序依次变差：Alb>35.2、LTI>11.5组，Alb>35.2、LTI≤11.5组，Alb≤35.2、LTI>11.5组，Alb≤35.2、LTI≤11.5组。交互作用分析显示血Alb和LTI不存在交互作用。(4)亚组分析显示，血液透析亚组(n＝696)结果与总体类似，而腹膜透析亚组(n＝123)显示LTI、FTI与患者预后关系不明显。

结论

低LTI、高FTI、高ECW/BCM、液体负荷过量与患者中期死亡显著相关，而单个点的OH与中期死亡无显著相关。即使在校正年龄、Charlson共病评分后，LTI仍独立于Alb与预后相关，且两者间无交互作用，提示LTI联合血清Alb可评价尿毒症患者的营养指标和判断预后。

关键词: 尿毒症, 人体成分分析, 营养, 液体负荷, 瘦体重指数
Objective

To explore the predictive value of single-measured nutritional and fluid load parameters by bioelectrical impedance in the prognosis of hospitalized uremic patients undergoing dialysis.

Methods

Adult uremic patients undergoing maintenance dialysis (including hemodialysis and peritoneal dialysis) were recruited prospectively and continuously from the Department of Nephrology, the First Affiliated Hospital of Nanjing Medical University from January 2014 to December 2016. The body composition was measured by bioelectrical impedance method before dialysis within 3 days after admission. Kaplan-Meier method was used to plot survival curves. Cox regression analysis was used to analyze the relationship between prognosis and the following body composition analysis parameters: lean tissue index (LTI), fat tissue index (FTI), the ratio of extracellular water (ECW) to body cell mass (BCM), and over hydration (OH). The multivariate-correcting Cox regression analysis was also performed.

Results

(1) A total of 819 patients were enrolled including 696 hemodialysis patients and 123 peritoneal dialysis patients after excluding 12 patients of loss to follow-up and 20 patients who underwent renal transplantation during the follow-up period. The mean follow-up time was 28.1±9.7 months while 172 (21%) patients died in the duration of follow-up. (2)The patients were divided into three groups according to OH < -1 L, -1 L~1 L and >1 L, into fluid overload group and fluid balance group according to the OH/ECW ratio, and into 4 groups according to the quartiles of LTI, FTI or ECM/BCM. Survival analysis found no significant difference in death between patients in different OH groups (χ2=2.4767, P=0.2899), while there were significant differences in death between the two groups of patients with different body fluid status (χ2=12.3874, P=0.0004), and among the different four groups of LTI (χ2=57.0897, P<0.0001), FTI (χ2=10.5650, P=0.0143), or ECW/BCM (χ2=69.5081, P<0.0001). In the fluid overload group, the lower-LTI groups, the higher-FTI groups, and the higher-ECW/BCM groups, the risk of death tends to increase. After adjustment of dialysis-age, diabetes, infection, diastolic blood pressure, FTI, and ECW/BCM, the multifactor COX regression analysis showed that higher age, higher Charlson index, lower serum albumin (Alb), and lower LTI were all independent risk factors for the death of dialysis patients (HRage =1.03, P<0.001; HRCharlson=1.18, P=0.003; HRAlb=0.94, P<0.001; HRLTI=0.84, P<0.001). (3) According to the medians of Alb and LTI, the population was divided into 4 groups, and the prognosis was found to be worse in the following grouping order: Alb>35.2 and LTI>11.5 group, Alb>35.2 and LTI≤11.5 group, Alb≤35.2 and LTI>11.5 group, and Alb≤35.2 and LTI≤11.5 group. Interaction analysis showed that there was no interaction between blood Alb and LTI. (4) Subgroup analysis showed that the results of hemodialysis subgroup (n=696) were similar to those of the general population, while FTI and LTI of the peritoneal dialysis subgroup (n=123) had no significant relationship with the prognosis of patients.

Conclusion

Lower LTI, higher FTI, higher ECW/BCM, and fluid overload were significantly associated with midterm death of patients, while single-measure OH value had no significant correlation with the midterm death of dialysis patients. Even after adjusting for age and Charlson comorbidity score, the LTI was still independent of Alb and associated with prognosis, and there was no interaction between them, suggesting that LTI combined with serum Alb could be used for evaluating nutritional indicators and prognosis of uremic patients.

Key words: Uremia, Body composition analysis, Nutrition, Liquid load, Lean Tissue Index
表1 总体研究人群及LTI分组人群基线情况及死亡率
? LTI分组(kg/m2)
总体 ≤9.7 9.8～11.4 11.5～13.2 >13.2 卡方值 P值
人数 819 211 202 204 202 ? ?
一般情况和预后 ? ? ? ? ? ? ?
? 年龄(岁) 53.6±15.5 61.4±16.8 55.4±13.8 51.7±13.9 45.7±12.8 116.0312 <0.001
? 性别(男/女) 461/358 68/143 92/110 128/76 173/29 133.1634 <0.001
? 身高(cm) 164.9±7.7 162.0±7.6 163.5±7.0 165.8±7.6 168.6±7.3 88.2726 <0.001
? 体重(kg) 61.1±12.3 57.5±11.2 59.0±10.6 61.5±12.2 66.4±13.4 51.9517 <0.001
? 体重指数(kg/ m2) 22.3±3.8 21.9±3.9 21.9±3.4 22.3±3.6 23.3±4.0 15.4935 0.001
? 透析龄(月) 52.0±52.7 43.4±50.2 62.5±57.7 54.0±51.0 44.6±47.2 15.3028 0.002
合并症[例数(%)] ? ? ? ? ? ? ?
? 高血压 669(81.7) 169(80.1) 164(81.2) 163(79.9) 173(85.6) 2.9357 0.4016
? 糖尿病 189(23.1) 67(31.8) 51(25.2) 40(19.6) 31(15.3) 17.6462 0.0005
? 感染 234(28.6) 80(37.9) 64(31.7) 53(26.0) 37(18.3) 21.0378 0.0001
Charlson评分 3.0±1.3 3.4±1.5 3.0±1.2 2.8±1.2 2.7±1.0 35.0820 <0.0001
实验室检查结果 ? ? ? ? ? ? ?
? 血红蛋白(g/L) 93.5±23.1 91.8±21.3 95.6±23.3 92.2±23.1 94.3±24.4 2.6234 0.4534
? 血白蛋白(g/L) 34.6±6.2 33.5±5.7 34.8±6.0 34.0±6.7 36.1±6.2 18.7730 0.0003
? 转铁蛋白(g/L) 1.9±0.5 1.8±0.5 1.9±0.5 1.8±0.5 2.0±0.5 13.0354 0.0046
? 总甘油三酯(mmol/L) 1.8±1.6 1.9±1.6 2.0±2.2 1.6±0.9 1.7±1.4 4.5174 0.2107
? 总胆固醇(mmol/L) 4.3±1.3 4.4±1.4 4.4±1.4 4.4±1.3 4.2±1.1 2.5982 0.4578
? C反应蛋白(mg/L) 29.0±44.3 37.2±45.6 33.3±45.8 27.2±49.7 14.2±25.7 36.1056 <0.0001
人体成分分析参数 ? ? ? ? ? ? ?
? OH (L) 2.2±2.5 1.6±1.7 2.1±2.1 2.8±3.1 2.1±2.8 13.5572 0.0036
? FTI (kg/m2) 10.0±4.3 12.7±4.5 10.4±3.5 8.9±3.6 7.8±3.8 156.6941 <0.0001
? ECW (L) 15.0±3.6 13.0±2.5 14.3±2.9 15.9±3.8 16.9±3.7 166.0589 <0.0001
? BCM (kg) 16.8±7.9 10.1±2.2 15.3±11.4 18.1±2.1 23.8±3.4 707.3527 <0.0001
? OH/ECW 0.1±0.1 0.1±0.1 0.1±0.1 0.2±0.1 0.1±0.1 13.7218 0.0033
? ECW/BCM 1.0±0.4 1.4±0.5 1.0±0.2 0.9±0.2 0.7±0.1 469.8200 <0.0001
? 随访死亡率[例数(%)] 172(21.0) 81(37.9) 39(20.1) 37(15.7) 15(7.9) 62.1699 <0.0001
图1 OH、FC、LTI、FTI、ECW/BCM、LTI与ALB不同分组的Kaplan－Meier生存曲线分析
表2 单因素COX回归分析维持性透析患者死亡的危险因素
变量 HR(95%Cl) P值
年龄(岁) 1.05(1.04，1.07) P<0.001
性别(男/女) 0.88(0.63，1.23) P＝0.463
体重指数(kg/ m2) 0.98(0.94，1.03) P＝0.468
透析龄(月) 0.99(0.99，1.00) P＝0.005
高血压(1/0) 1.07(0.69，1.67) P＝0.751
糖尿病(1/0) 2.75(1.97，3.84) P<0.001
感染(1/0) 2.24(1.61，3.13) P<0.001
Charlson评分(分) 1.43(1.31，1.56) P<0.001
血红蛋白(g/L) 0.99(0.99，1.00) P＝0.184
血白蛋白(g/L) 0.92(0.90，0.95) P<0.001
收缩压(mmHg) 1.00(0.99，1.00) P＝0.791
舒张压(mmHg) 0.98(0.97，0.99) P<0.001
OH(每增加1L) 1.04(0.98，1.11) P＝0.223
LTI(kg/m2) 0.75(0.70，0.81) P<0.001
FTI(kg/m2) 1.07(1.03，1.10) P<0.001
ECW/BCM(每增加1) 2.36(2.00，2.78) P<0.001
表3 COX比例风险回归模型
变量 参数估计 标准误差 HR(95%Cl) P值
年龄(岁) 0.03 0.01 1.03 (1.02～1.05) <0.001
Charlson评分(分) 0.16 0.06 1.18(1.06～1.31) 0.003
血白蛋白(g/L) －0.07 0.01 0.94(0.91～0.96) <0.001
LTI (kg/m2) －0.17 0.04 0.84 (0.77～0.91) <0.001
表4 血液透析亚组的COX比例风险回归模型(n＝696)
变量 参数估计 标准误差 HR(95%Cl) P值
年龄(岁) 0.03 0.01 1.03(1.02～1.05) <0.001
深静脉导管(0/1) －0.45 0.22 0.64(0.42～0.97) 0.036
Charlson评分(分) 0.18 0.06 1.20(1.07～1.35) 0.002
血白蛋白(g/L) －0.08 0.02 0.92(0.89～0.96) <0.001
LTI (kg/m2) －0.17 0.05 0.84 (0.77～0.93) <0.001
表5 腹膜透析亚组的COX比例风险回归模型(n＝123)
变量 参数估计 标准误差 HR(95%Cl) P值
年龄(岁) 0.06 0.02 1.07(1.03～1.10) <0.001
ECW/BCM ? ? ? ?
(每增长1) 0.64 0.19 1.90(1.30～2.77) <0.001
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