血清甲状旁腺激素水平结合控制营养状态评分对腹膜透析置管相关性腹膜炎发生预测及预后影响

doi:10.3969/j.issn.1004-583X.2023.11.005

摘要/Abstract

摘要：

目的探讨营养不良和血清全段甲状旁腺激素(intact parathyroid hormone,iPTH)水平对腹膜透析置管相关性腹膜炎发生及对预后的影响。方法回顾性分析2018年1月1日至2022年4月30日在青岛大学附属医院因尿毒症行腹膜透析置管手术住院的患者,随访至2022年7月30日,采用Kaplan-Meier生存曲线及Cox回归分析iPTH和控制营养状态评分(controlling nutritional status,CONUT)对腹膜透析置管相关性腹膜炎发生及预后的影响。结果本研究纳入腹膜透析患者193例,年龄(51.50±16.85)岁,男性117例(60.6%)。根据血iPTH水平及CONUT评分分为4组,其中低甲状旁腺激素血症(iPTH<150 pg/ml,Hypo-PTH)合并中重度营养不良(CONUT>4)组42例(21.76%);4组在原发病是慢性肾小球肾炎、狼疮性肾炎及糖尿病肾病的分布及心力衰竭的发生率方面差异有统计学意义( $P$ <0.05)。应用激素或免疫抑制剂治疗人数最多的是低甲状旁腺激素血症合并中重度营养不良组。4组年龄、血红蛋白、血尿酸、CRP、BNP、血钠、血钙、血磷、血清白蛋白、血清球蛋白差异有统计学意义( $P$ <0.05)。Hypo-PTH合并中重度营养不良组术后30天内腹膜炎发生率最高(26.19%)。Cox回归分析显示,Hypo-PTH合并中重度营养不良组腹膜炎发生风险最高, $H R$ 为5.206(95% $C I$ 1.594,17.002; $P$ =0.006),在调整年龄、性别、BMI、血红蛋白、CRP、血尿酸、BNP等指标后, $H R$ 仍为5.187(95% $C I$ 1.465,18.360; $P$ =0.011)。Hypo-PTH合并中重度营养不良组预后不良发生率明显高于其他三组, $H R$ 为2.998(95% $C I$ 1.328,6.766; $P$ =0.008),矫正后 $H R$ 为2.665(95% $C I$ 1.089,6.522; $P$ =0.032)。结论腹膜透析患者低甲状旁腺激素水平与中重度营养不良并存是腹膜透析置管相关性腹膜炎发生的危险因素,可直接导致腹膜透析患者预后不良。

关键词: 腹膜透析, 甲状旁腺激素, 腹膜炎, 营养

Abstract:

Objective To investigate the effects of malnutrition and serum intact parathyroid hormone (iPTH) level on the incidence and prognosis of peritoneal dialysis catheter-related peritonitis. Methods A retrospective analysis was performed on hospitalized patients with uremia who underwent peritoneal dialysis catheterization in the Affiliated Hospital of Qingdao University from January 1, 2018 to April 30, 2022 and they were followed up until July 30, 2022. Kaplan-Meier survival curve and Cox regression were used to analyze the effects of iPTH and the Controlling Nutritional Status (CONUT) score on the occurrence and prognosis of peritoneal dialysis catheter-related peritonitis. Results A total of 193 patients with peritoneal dialysis were included in this study, with the mean age of (51.50±16.85) years old and 117 (60.6%) males. According to blood iPTH level and CONUT score, patients were divided into four groups. Forty-two cases (21.76%) presented low parathyroid hormone (iPTH<150 pg/ml, Hypo-PTH) combined with moderate-to-severe malnutrition (CONUT>4). There were significant differences in the distribution of chronic glomerulonephritis, lupus nephritis, diabetic nephropathy and the incidence of heart failure between groups ( $P$ <0.05). The largest number of patients treated with hormone or immunosuppressants was found in those with low parathyroid hormone and moderate-to-severe malnutrition. There were significant differences in age, hemoglobin, blood uric acid, C-reactive protein (CRP), B-type natriuretic peptide (BNP), blood sodium, blood calcium, blood phosphorus, albumin and globulin between groups ( $P$ <0.05). The highest incidence of peritonitis within 30 days after operation was 26.19% in patients with Hypo-PTH group and moderate-to-severe malnutrition. Cox regression analysis showed that this group had the highest risk of peritonitis, with a hazard ratio ( $H R$ ) of 5.206 (95% $C I$ 1.594, 17.002; $P$ =0.006). After adjusting for age, sex, BMI, hemoglobin, CRP, blood uric acid, BNP and other indicators, HR was still 5.187 (95% $C I$ 1.465, 18.360; $P$ =0.011). The incidence of poor prognosis was also significantly higher than that of the other three groups, with a $H R$ of 2.998 (95% $C I$ 1.328, 6.766; $P$ =0.008) and adjusted $H R$ of 2.665 (95% $C I$ 1.089, 6.522; $P$ =0.032). Conclusion The coexistence of hypoparathyroidism and moderate-to-severe malnutrition in patients with peritoneal dialysis is the risk factor for peritonitis after peritoneal dialysis catheterization, which can directly lead to the poor prognosis.

Key words: peritoneal dialysis, parathyroid hormone, peritonitis, nutrition

中图分类号:

R459.5

公智卿, 卢冬梅, 邢广群. 血清甲状旁腺激素水平结合控制营养状态评分对腹膜透析置管相关性腹膜炎发生预测及预后影响[J]. 临床荟萃, 2023, 38(11): 991-995.

Gong Zhiqing, Lu Dongmei, Xing Guangqun. The predictive and prognostic potential of serum parathyroid hormone combined with the nutritional status score on peritoneal dialysis catheter-related peritonitis[J]. Clinical Focus, 2023, 38(11): 991-995.

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链接本文: https://huicui.hebmu.edu.cn/CN/10.3969/j.issn.1004-583X.2023.11.005

https://huicui.hebmu.edu.cn/CN/Y2023/V38/I11/991

图/表 5

表1 4组一般资料比较

Tab.1 Comparison of general information between groups

项目	hypo-PTH		非hypo-PTH		$P$ 值
项目	CONUT>4分 ( $n$ =42)	CONUT≤4分 ( $n$ =25)	CONUT>4分 ( $n$ =59)	CONUT≤4分 ( $n$ =67)	$P$ 值
男性[例(%)]	27(64.3)	11(44.0)	34(57.6)	45(67.2)	0.208
年龄(岁)	54.48±17.77	50.92±20.11	55.86±14.52	46.00±15.63^*#	0.005
BMI(kg/m²)	22.94±4.49	23.85±3.73	24.81±4.47	24.14±4.12	0.189
原发病[例(%)]
慢性肾小球肾炎	3(7.1)	6(24.0)	18(30.5)^*	27(40.3)^*	0.002
糖尿病肾病	14(33.3)	5(20.0)	24(40.7)	9(13.4)^#	0.004
高血压肾病	4(9.5)	6(24.0)	7(11.9)	12(17.9)	0.333
狼疮性肾炎	9(21.4)	4(16.0)	3(5.1)^*	3(4.5)^*	0.011
其他病因	12(28.6)	4(16.0)	7(11.9)	16(23.9)	0.157
合并症[例(%)]
心力衰竭					0.035
NYHA心功能
Ⅰ-Ⅱ级	7(16.7)	3(12.0)	15(25.4)	6(9.0)
Ⅲ-Ⅳ级	13(30.9)	7(28.0)	17(28.8)	11(16.4)
无心力衰竭	22(52.4)	15(60.0)	27(45.8)	50(74.6)^#
除腹膜炎外其他部位的感染	12(28.6)	6(24.0)	11(18.6)	7(11.1)	0.089
乙肝或肝硬化	2(4.8)	1(4.0)	9(15.3)	11(16.4)	0.149
激素或免疫抑制剂使用[例(%)]	16(38.1)	5(20.0)	4(6.8)^*	6(9.0)^*	<0.01

表1 4组一般资料比较

Tab.1 Comparison of general information between groups

项目	hypo-PTH		非hypo-PTH		$P$ 值
项目	CONUT>4分 ( $n$ =42)	CONUT≤4分 ( $n$ =25)	CONUT>4分 ( $n$ =59)	CONUT≤4分 ( $n$ =67)	$P$ 值
男性[例(%)]	27(64.3)	11(44.0)	34(57.6)	45(67.2)	0.208
年龄(岁)	54.48±17.77	50.92±20.11	55.86±14.52	46.00±15.63^*#	0.005
BMI(kg/m²)	22.94±4.49	23.85±3.73	24.81±4.47	24.14±4.12	0.189
原发病[例(%)]
慢性肾小球肾炎	3(7.1)	6(24.0)	18(30.5)^*	27(40.3)^*	0.002
糖尿病肾病	14(33.3)	5(20.0)	24(40.7)	9(13.4)^#	0.004
高血压肾病	4(9.5)	6(24.0)	7(11.9)	12(17.9)	0.333
狼疮性肾炎	9(21.4)	4(16.0)	3(5.1)^*	3(4.5)^*	0.011
其他病因	12(28.6)	4(16.0)	7(11.9)	16(23.9)	0.157
合并症[例(%)]
心力衰竭					0.035
NYHA心功能
Ⅰ-Ⅱ级	7(16.7)	3(12.0)	15(25.4)	6(9.0)
Ⅲ-Ⅳ级	13(30.9)	7(28.0)	17(28.8)	11(16.4)
无心力衰竭	22(52.4)	15(60.0)	27(45.8)	50(74.6)^#
除腹膜炎外其他部位的感染	12(28.6)	6(24.0)	11(18.6)	7(11.1)	0.089
乙肝或肝硬化	2(4.8)	1(4.0)	9(15.3)	11(16.4)	0.149
激素或免疫抑制剂使用[例(%)]	16(38.1)	5(20.0)	4(6.8)^*	6(9.0)^*	<0.01

表2 4组实验室资料比较

Tab.2 Comparison of laboratory data between groups

项目	Hypo-PTH		非Hypo-PTH		$P$ 值
项目	CONUT>4分( $n$ =42)	CONUT≤4分( $n$ =25)	CONUT>4分( $n$ =59)	CONUT≤4分( $n$ =67)	$P$ 值
iPTH( pg/ml)	78.51±41.13	73.07±43.65	347.35±212.02^*&	366.26±195.36^*&	<0.01
CONUT	7(5,8)	3(1, 4)^*#	6(5, 7)	3(2, 4)^*#	<0.01
白细胞计数(×10⁹/L)	7.47±4.76	6.83±2.08	6.25±2.54	6.56±2.16	0.236
血红蛋白(g/L)	90.29±18.16	87.28±12.55	78.76±12.29^*&	86.70±13.96^#	0.001
血小板计数(×10⁹/L)	168.10±77.36	180.28±65.03	142.98±65.39	165.79±58.60	0.064
血钠(mmol/L)	138.96±4.79^&	136.72±3.49	139.03±3.60^&	139.38±3.70^&	0.035
血钾(mmol/L)	4.30±0.75	4.29±0.75	4.33±0.62	4.57±0.75	0.131
尿素氮(mmol/L)	22.82±10.71^&	44.16±30.74	31.72±11.49	34.98±12.35^*	0.037
肌酐(μmol/L)	507.16±249.27	843.37±542.23^*	796.04±319.46^*	976.65±376.67^*#	<0.01
尿酸(μmol/L)	376.66±167.09	443.39±150.23	396.20±133.96	472.27±165.67^*#	0.006
血钙(mmol/L)	1.96±0.24	2.08±0.19	1.82±0.22	1.91±0.21^&#	<0.01
血磷(mmol/L)	1.60±0.58	1.76±0.67	1.93±0.56	2.17±0.56^*&#	<0.01
白蛋白(g/L)	26.81±5.76	35.40±3.97	29.53±3.65	37.04±3.99^*#	<0.01
球蛋白(g/L)	23.96±9.42	26.48±5.55	24.24±8.80	18.50±19.29^*&#	0.022
CRP(mg/L)	4.69(1.09, 20.73)	5.50(0.63, 12.00)	6.37(1.64, 29.68)	1.36(0.50, 6.17)^#	0.004
总胆固醇(mmol/L)	5.14±2.67	5.17±1.51	4.46±1.37	4.57±1.04	0.106
BNP( pg/ml)	337.05(143.23,1428.35)	204.90(104.35,1246.35)	793.70(286.30,1261.00)	220.25(98.13, 577.38)^#	0.004

表2 4组实验室资料比较

Tab.2 Comparison of laboratory data between groups

项目	Hypo-PTH		非Hypo-PTH		$P$ 值
项目	CONUT>4分( $n$ =42)	CONUT≤4分( $n$ =25)	CONUT>4分( $n$ =59)	CONUT≤4分( $n$ =67)	$P$ 值
iPTH( pg/ml)	78.51±41.13	73.07±43.65	347.35±212.02^*&	366.26±195.36^*&	<0.01
CONUT	7(5,8)	3(1, 4)^*#	6(5, 7)	3(2, 4)^*#	<0.01
白细胞计数(×10⁹/L)	7.47±4.76	6.83±2.08	6.25±2.54	6.56±2.16	0.236
血红蛋白(g/L)	90.29±18.16	87.28±12.55	78.76±12.29^*&	86.70±13.96^#	0.001
血小板计数(×10⁹/L)	168.10±77.36	180.28±65.03	142.98±65.39	165.79±58.60	0.064
血钠(mmol/L)	138.96±4.79^&	136.72±3.49	139.03±3.60^&	139.38±3.70^&	0.035
血钾(mmol/L)	4.30±0.75	4.29±0.75	4.33±0.62	4.57±0.75	0.131
尿素氮(mmol/L)	22.82±10.71^&	44.16±30.74	31.72±11.49	34.98±12.35^*	0.037
肌酐(μmol/L)	507.16±249.27	843.37±542.23^*	796.04±319.46^*	976.65±376.67^*#	<0.01
尿酸(μmol/L)	376.66±167.09	443.39±150.23	396.20±133.96	472.27±165.67^*#	0.006
血钙(mmol/L)	1.96±0.24	2.08±0.19	1.82±0.22	1.91±0.21^&#	<0.01
血磷(mmol/L)	1.60±0.58	1.76±0.67	1.93±0.56	2.17±0.56^*&#	<0.01
白蛋白(g/L)	26.81±5.76	35.40±3.97	29.53±3.65	37.04±3.99^*#	<0.01
球蛋白(g/L)	23.96±9.42	26.48±5.55	24.24±8.80	18.50±19.29^*&#	0.022
CRP(mg/L)	4.69(1.09, 20.73)	5.50(0.63, 12.00)	6.37(1.64, 29.68)	1.36(0.50, 6.17)^#	0.004
总胆固醇(mmol/L)	5.14±2.67	5.17±1.51	4.46±1.37	4.57±1.04	0.106
BNP( pg/ml)	337.05(143.23,1428.35)	204.90(104.35,1246.35)	793.70(286.30,1261.00)	220.25(98.13, 577.38)^#	0.004

表3 4组术后30天内腹膜炎发生率比较

Tab.3 Comparison of the incidence of peritonitis within 30 days after operation between groups

组别	例数	腹膜炎发生率[例(%)]
iPTH≥150 pg/ml,CONUT≤4	67	8(11.94)
iPTH<150 pg/ml,CONUT>4	42	11(26.19)
iPTH<150 pg/ml,CONUT≤4	25	5(20.00)
iPTH≥150 pg/ml,CONUT>4	59	10(16.95)
χ²值
$P$ 值

表3 4组术后30天内腹膜炎发生率比较

Tab.3 Comparison of the incidence of peritonitis within 30 days after operation between groups

组别	例数	腹膜炎发生率[例(%)]
iPTH≥150 pg/ml,CONUT≤4	67	8(11.94)
iPTH<150 pg/ml,CONUT>4	42	11(26.19)
iPTH<150 pg/ml,CONUT≤4	25	5(20.00)
iPTH≥150 pg/ml,CONUT>4	59	10(16.95)
χ²值
$P$ 值

图1 腹膜透析患者的Kaplan-Meier生存曲线

Fig.1 Kaplan-Meier survival curves for peritoneal dialysis patients

图2 Cox多因素回归分析森林图 a.PTH及CONUT评分对腹膜透析相关性腹膜炎的影响;b. PTH及CONUT对腹膜透析患者不良预后的影响

Fig.2 Forest plot of the cox multivariate regresion analysis a.the cox multivariate regression analysis of PTH and CONUT score for peritoneal dialysis-related peritonitis; b. the cox multivariate regression analysis of PTH and CONUT on poor prognosis in peritoneal dialysis patients

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