糖尿病或新发高血糖对腹膜透析患者预后的影响

杜若梅; 张威; 纪天蓉; 孔凡武

doi:10.3969/j.issn.1671-2390.2023.03.001

糖尿病或新发高血糖对腹膜透析患者预后的影响

Effects of diabetes or new-onset hyperglycemia on prognosis in peritoneal dialysis patients

摘要

摘要: 目的探讨糖尿病(diabetes mellitus,DM)或腹膜透析(peritoneal dialysis,PD)后新发空腹血糖(fasting plasma glucose,FPG)升高对PD患者预后的影响,分析PD后新发FPG升高的比例及其预测因子。方法回顾性分析2009年3月至2021年10月于哈尔滨医科大学附属第二医院肾内科开始PD治疗的成年患者的基线特征和实验室数据。根据PD开始时是否合并DM将患者分为两组,A组:DM组;B组:非DM组。再根据PD开始后是否发生新发FPG升高(至少2次复查结果FPG≥7.0 mmol/L),将B组分为两个亚组:B_c组,高FPG组;B_d组,非高FPG组。通过Kaplan-Meier生存曲线比较各组及各亚组间的差异,Cox回归模型分析PD患者死亡及新发FPG升高的潜在预测因子。结果本研究共纳入474例患者,DM组129例(27.2%),非DM组345例(72.8%)。与非DM组相比,DM组患者的累积生存率显著更低(log-rank=25.756,P＜0.001),但两组间的技术生存率差异并无统计学意义(log-rank=0.061,P=0.805)。多变量Cox回归分析的结果表明,合并DM(HR=1.728,95%CI:1.110~2.690,P=0.016)、冠心病(HR=2.793,95%CI:1.518~5.140,P=0.001)、甲状旁腺激素水平较低(HR=0.360,95%CI:0.235~0.551,P＜0.001)和血红蛋白水平较低(HR=0.559,95%CI:0.373~0.838,P=0.005)是PD患者死亡的独立危险因素。在345例非DM组患者中,有23例(6.7%)患者发生了FPG升高。总尿素清除指数(Kt/V)水平较低(HR=0.264,95%CI:0.085~0.816,P=0.021)和血钾水平较低(HR=0.234,95%CI:0.070~0.779,P=0.018)是FPG升高的独立预测因子。结论与非DM组相比,DM组PD患者的病死率较高,但没有更高的腹膜炎及超滤衰竭的发生率。非DM的PD患者中FPG升高的比例是6.7%。总Kt/V水平较低或血钾水平较低是PD患者FPG升高的独立预测因素。

Abstract: Objective To explore the effects of diabetes mellitus(DM) or newly-onset fasting plasma glucose(FPG) elevation after peritoneal dialysis(PD) on the prognosis of PD patients and analyze the proportion and predictors of newly-onset FPG elevation after PD therapy.Methods From March 2009 to October 2021,retrospective review was conducted for baseline profiles and laboratory data of 474 adult patients on PD.They were divided into two groups of diabetic(n=129) and non-diabetic(n=345) according to the presence or absence of DM at the start of PD.Group B was assigned into two subgroups according to whether or not newly-onset FPG elevation(results of at least 2 re-examinations showing FPG ≥7.0 mmol/L) occurred after initialing PD:Group Bc:elevated FPG group,Group Bd:non-elevated FPG group.Differences between groups and subgroups were compared by Kaplan-Meier survival curves and Cox regression model for examining potential predictors of mortality and new-onset elevated fasting glucose in PD patients.Results Cumulative survival rate was significantly lower in diabetic group than that in non-diabetic group(Log-rank=25.756,P＜0.001).However,inter-group difference in technical survival was insignificant(Log-rank=0.061,P=0.805).Multivariate Cox regression analysis revealed that DM(HR=1.728,95%CI:1.110-2.690,P=0.016),coronary heart disease(HR=2.793,95%CI:1.518-5.140,P=0.001),lower parathyroid hormone(PTH)(HR=0.360,95%CI:0.235-0.551,P＜0.001) and lower hemoglobin(Hb)(HR=0.559,95%CI:0.373-0.838,P=0.005) were independent risk factors for mortality in PD patients.In non-diabetic group,23(6.7%) developed newly-onset fasting plasma hyperglycemia.Lower total urea clearance index(Kt/V)(HR=0.264,95%CI:0.085-0.816,P=0.021) and lower serum potassium levels(HR=0.234,95%CI:0.070-0.779,P=0.018) were independent predictors of newly-onset fasting plasma hyperglycemia.Conclusion As compared with non-diabetics,PD diabetics have a higher mortality rate.However,there is no higher incidence of peritonitis or ultrafiltration failure.The proportion of newly-onset fasting plasma hyperglycemia is 6.7% in non-diabetic PD patients.Lower total Kt/V or lower serum potassium are independent predictors of newly-onset fasting plasma hyperglycemia.

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