慢性肾脏病血液透析患者透析间期不同血钾水平与自体动静脉内瘘血栓形成的相关性分析

Correlation analysis between different serum potassium levels during the hemodialysis interval and thrombosis of autologous arteriovenous fistula in patients with chronic kidney disease

摘要:

目的]探究慢性肾脏病(CKD)维持性血液透析(MHD)患者透析间期平均血钾水平对患者自体动静脉内瘘(AVF)血栓形成的影响。 [方法]回顾性分析2021年10月—2022年10月于本院进行MHD的CKD患者159例,根据患者不同透析间期平均血钾水平,将患者分为高血钾组(n＝53)、血钾正常组(n＝61)及低血钾组(n＝45),对所有患者均随访1年或随访至AVF血栓形成。收集患者一般资料,检测患者入组时生物化学指标、炎症因子、AVF超声指标及氧化应激因子水平。采用多因素Logistic回归方程分析临床指标对MHD患者AVF血栓形成的影响；采用受试者工作特征(ROC)曲线评估临床指标对MHD患者AVF血栓形成的预测效能；采用区间似然比对间期平均血钾水平进行分层分析,进一步观察MHD患者AVF血栓形成与间期平均血钾水平之间的关系是否稳定。 [结果]与血钾正常组相比,高血钾组和低血钾组的C反应蛋白(CRP)、全段甲状旁腺激素(iPTH)、降钙素原(PCT)、甘油三酯(TG)、丙二醛(MDA)、髓过氧化物酶(MPO)、肱动脉阻力指数(RI)、肱动脉搏动指数(PI)、桡动脉PI水平均明显升高,而白蛋白(Alb)、总胆固醇(TC)、超氧化物歧化酶(SOD)水平及内瘘血流量均明显降低,差异均具有统计学意义(P＜0.05)。AVF血栓形成患者收缩压、舒张压、内瘘血流量、Alb及SOD水平明显低于AVF血栓未形成患者(P＜0.05)；AVF血栓形成患者间期平均血钾水平、CRP、iPTH、PCT、肱动脉RI、肱动脉PI、桡动脉PI、桡动脉RI、MDA及MPO水平明显高于AVF血栓未形成患者(P＜0.05)。ROC曲线对多因素Logistic回归方程所建立的模型进行分析,发现模型一、模型二均具有较为良好的预测效能,且模型二的预测效能最佳；区间似然比结果显示,当患者间期平均血钾水平为3.5~4.5 mmol/L时,患者AVF血栓形成的可能性最低,当患者间期平均血钾水平＞5.5 mmol/L或＜3.5 mmol/L时,患者AVF血栓形成的可能性较高,当患者间期平均血钾水平＞5.5 mmol/L时,患者AVF血栓形成的概率最高,是未发生AVF血栓患者的3.925倍。 [结论]透析间期平均血钾水平异常可能诱发CKD患者出现AVF血栓形成,可在MHD治疗期间对血钾水平进行监测,以便及时进行干预,提升患者临床治疗效果。

Abstract:

Aim To investigate the effect of interdialytic serum potassium levels on thrombosis of autologous arteriovenous fistula (AVF) in patients with chronic kidney disease (CKD) on maintenance haemodialysis (MHD). Methods 159 CKD patients who underwent MHD in our hospital from October 2021 to October 2022 were retrospectively analyzed. They were divided into hyperkalemia group (n＝53), normal serum potassium group (n＝61) and hypokalemia group (n＝45) according to the mean serum potassium level of patients with different dialysis intervals, and all patients were followed up for 1 year or followed up until AVF thrombosis. General datas were collected and the following indicators were detected at the time of patient enrolment, including biochemical indicators, inflammatory factors, ultrasound indicators of AVF and oxidative stress factors levels. Multifactorial Logistic regression equations were used to analyze the effects of clinical indicators on AVF thrombosis in MHD patients, receiver operating characteristic (ROC) curve was used to assess the predictive efficacy of clinical indicators on AVF thrombosis; And interval likelihood ratio was used to stratify interdialytic serum potassium levels, and further observe whether the relationship was stability between AVF thrombosis and interdialytic serum potassium levels in MHD patients. Results Compared with the normal serum potassium group, the levels of C-reactive protein (CRP), intact parathyroid hormone (iPTH), procalcitonin (PCT), triglyceride (TG), malondialdehyde (MDA), myeloperoxidase (MPO), brachial artery resistance index (RI), brachial artery pulsatility index (PI) and radial artery PI were significantly elevated in hyperkalemia group and hypokalemia group, while the levels of albumin (Alb), total cholesterol (TC), superoxide dismutase (SOD) and fistula blood flow were significantly reduced (P＜0.05).Systolic blood pressure, diastolic blood pressure, fistula blood flow, Alb and SOD levels were significantly lower in patients with AVF thrombosis than those in patients with AVF unthrombosis (P＜0.05); Interdialytic mean serum potassium level, CRP, iPTH, PCT, brachial artery RI, brachial artery PI, radial artery PI, radial artery RI, MDA and MPO levels were significantly higher in patients with AVF thrombosis (P＜0.05). The ROC curve was used to analyse the model established by the multifactorial Logistic regression equation, and it was found that model 1 and model 2 had good predictive efficacy, and model 2 had the best predictive efficacy. The results of the interval likelihood ratio showed that:when the patient's interdialytic serum potassium level was 3.5～4.5 mmol/L, the possibility of the patient's AVF thrombosis was the lowest, and when the patient's interdialytic serum potassium level was ＞5.5 mmol/L or ＜3.5 mmol/L, the possibility of the patient's AVF thrombosis was higher, and when the patient's serum potassium level was ＞5.5 mmol/L, the probability of AVF thrombosis was the highest in patients, which was 3.925 times higher than that of patients without AVF thrombosis. Conclusion Abnormal interdialytic serum potassium levels may induce AVF thrombosis in CKD patients. Serum potassium levels can be monitored during MHD treatment to enable timely intervention and improve clinical treatment outcomes for patients.