中老年维持性血液透析患者认知功能损伤与全因死亡相关性的前瞻性队列研究  

A prospective cohort study on the association of cognitive impairment and all⁃cause mortality in the middle and elderly adult patients undergoing maintenance hemodialysis

作　　者：郭一丹 张春霞 田茹 叶鹏鹏 李国刚 李新[4] 卢方平[5] 马迎春 孙懿[7] 王玉柱[8] 肖跃飞[9] 张启蒙 赵海丹 赵雪峰 罗洋 Guo Yidan;Zhang Chunxia;Tian Ru;Ye Pengpeng;Li Guogang;Li Xin;Lu Fangping;Ma Yingchun;Sun Yi;Wang Yuzhu;Xiao Yuefei;Zhang Qimeng;Zhao Haidan;Zhao Xuefeng;Luo Yang(Department of Nephrology,Beijing Shijitan Hospital,Capital Medical University,Beijing 100038,China;Division of Injury Prevention and Mental Health National Center for Chronic and Non-communicable Disease Control and Prevention,Chinese Center for Disease Control and Prevention,Beijing 100053,China;Department of Nephrology,Beijing Shijingshan Hospital,Beijing 100047,China;Department of Nephrology,Beijing Chaoyang Hospital,Capital Medical University,Beijing 100032,China;Department of Nephrology,Beijing Huaxin Hospital,the First Hospital of Tsinghua University,Beijing 100084,China;Department of Nephrology,China Rehabilitation Research Center Beijing Boai Hospital,Beijing 100029,China;Department of Nephrology,Beijing Fuxing Hospital,Capital Medical University,Beijing 100036,China;Department of Nephrology,Beijing Haidian Hospital,Beijing 100058,China;Department of Nephrology,Aerospace Central Hospital,Beijing 100042,China;Department of Nephrology,Beijing Zhongguancun Hospital,Beijing 100586,China;Department of Nephrology,Peking University Shougang Hospital,Beijing 100574,China;Department of Nephrology,Nankou Hospital of Beijing Changping District,Beijing 100024,China)

机构地区：[1]首都医科大学附属北京世纪坛医院肾内科,北京100038 [2]中国疾病预防控制中心慢性非传染性疾病预防控制中心,北京100053 [3]北京石景山医院肾内科,北京100047 [4]首都医科大学附属北京朝阳医院肾内科,北京100032 [5]清华大学第一医院肾内科,北京100084 [6]中国康复中心北京博爱医院肾内科,北京100029 [7]首都医科大学附属北京复兴医院肾内科,北京100036 [8]北京市海淀医院肾内科,北京100058 [9]北京航天中心医院肾内科,北京100042 [10]北京市中关村医院肾内科,北京100586 [11]北京大学首钢医院肾脏科,北京100574 [12]北京市昌平区南口医院肾脏科,北京100024

出　　处：《中华肾脏病杂志》2021年第11期896-903,共8页Chinese Journal of Nephrology

基　　金：北京市科学技术委员会国家重大研发计划匹配项目(Z161100002616005)。

摘　　要：目的探讨中老年维持性血液透析(hemodialysis,HD)患者认知功能损伤对其全因死亡的影响。方法本研究采用前瞻性队列研究方法,选取2017年4月至6月期间北京市11个血液透析中心的维持性HD患者,对认知功能进行评估,根据第五版《精神障碍诊断与统计手册》(DSM⁃V)标准将患者诊断并分为认知功能正常组和损伤组;随访至2018年6月,终点事件为全因死亡。比较两组患者临床特征,采用Kaplan⁃Meier生存曲线比较累积生存率差异;采用多因素Cox比例风险回归模型分析患者全因死亡的影响因素,确定认知功能损伤及不同认知域损伤与全因死亡的关系。结果本研究共纳入613例维持性HD患者,其中认知功能损伤组496例(80.91%)。与认知功能正常组比较,认知功能损伤组呈现高龄,长透析龄,高比例的糖尿病、高血压和脑卒中病史,高水平血清iPTH,较低的受教育程度及尿素清除指数(均P<0.05)。随访(49.53±8.42)周后,Kaplan⁃Meier生存分析结果显示,认知功能损伤组患者累积生存率显著低于认知功能正常组(Log⁃rankχ^(2)=8.610,P=0.003)。多因素Cox回归分析结果显示,糖尿病史(HR=2.742,95%CI 1.598~4.723,P<0.001)、冠心病史(HR=1.906,95%CI 1.169~3.108,P=0.010)、透析龄(每增加1个月,HR=1.007,95%CI 1.003~1.011,P=0.001)、血浆白蛋白水平(每增加1 g/L,HR=0.859,95%CI 0.809~0.912,P<0.001)、认知功能损伤(HR=2.719,95%CI 1.088~6.194,P=0.032)与全因死亡独立相关。认知域中,记忆力损伤(HR=2.571,95%CI 1.442~4.584,P<0.001)和执行功能损伤(HR=3.311,95%CI 1.843~5.949,P=0.001)以及3、4、5个认知域联合损伤(HR=5.746,95%CI 1.880~17.565,P=0.002;HR=12.420,95%CI 3.690~41.802,P<0.001;HR=13.478,95%CI 3.381~53.728,P<0.001)亦与全因死亡独立相关。结论认知功能损伤是中老年维持性HD患者全因死亡增加的独立风险因素;记忆力、执行功能认知域损伤以及3、4、5个认知域联合损伤患者全因死亡风险显著升�Objective To investigate the association between cognitive impairment and all⁃cause mortality in middle and elderly adult patients undergoing maintenance hemodialysis(HD).Methods A prospective cohort study was conducted.Patients from 11 HD centers in Beijing between April and June 2017 were enrolled.Baseline data were collected,and a series of neuropsychological batteries covered 5 domains of cognitive function were applied for the assessment of cognitive function.The patients were then classified as normal and cognitive impairment groups according to the fifth version of the Diagnostic and Statistical Manual of Mental Disorders criteria(DSM⁃V)and followed⁃up until June 2018.The clinical characteristics of the two groups of patients were compared.Kaplan⁃Meier survival analysis was used to compare the difference in the cumulative survival rate between the two groups.Multivariate Cox regression model was used to analyze the independent influencing factors of all⁃cause mortality,to determine the relationship between cognitive impairment and different cognitive domain impairments and all⁃cause death.Results A total of 613 patients were enrolled,of which 496(80.91%)patients had cognitive impairment.Compared with the normal cognitive function group,the patients in the cognitive impairment group tended to be older,longer dialysis vintage,a higher proportion of diabetes,hypertension,and stroke,increased serum iPTH level,and lower education level and urea clearance index(Kt/V)(all P<0.05).After(49.53±8.42)weeks of follow⁃up,Kaplan⁃Meier survival analysis showed that the cumulative survival rate of cognitive impairment group was significantly lower than that of cognitive normal group(Log⁃rankχ^(2)=8.610,P=0.003).Multivariate Cox regression analysis showed that history of diabetes(HR=2.742,95%CI 1.598-4.723,P<0.001),coronary heart disease(HR=1.906,95%CI 1.169-3.108,P=0.010),dialysis vintage(every increase of 1 month,HR=1.007,95%CI 1.003-1.011,P=0.001),serum level of albumin(every increase of 1 g/L,HR=0.8

关 键 词：肾透析 认知 危险因素 死亡率 

分 类 号：R692.5[医药卫生—泌尿科学]