Selim G, Stojceva-Taneva O, Sikole A, Amitov V, Trajcevska L, Asani A, Trojacanec-Piponska S, Polenakovic M
Department of Nephrology, Clinical Centre, Skopje, R. Macedonia.
Prilozi. 2007 Jul;28(1):81-95.
Although anaemia management has improved in haemodialysis (HD) patients in recent years, many of them still have haemoglobin (Hb) levels below the current recommendations. The consequent anaemia could be one of the links between malnutrition and inflammation, and higher mortality in HD patients. The study objective was to determine the relationship between Hb levels and outcome in patients undergoing HD, accounting for inflammation and malnutrition. We retrospectively analysed a total of 236 patients on HD between January 2003 and December 2005, classified by absence or presence of inflammation and malnutrition (defined as serum albumin levels < 40 g/L and CRP > 8mg/l). Serum levels of Hb, ferritin, creatinine, cholesterol, triglycerides, HDL (high-density lipoprotein cholesterol), LDL (low-density lipoprotein cholesterol), albumin and CRP were measured monthly, fibrinogen was measured every third month. Over the period of three years, 73 out of 236 patients (30%) had died, most from cardiovascular diseases (62%). Presence of inflammation and malnutrition (in 44% of patients) was associated with older age (60.69 -/+ 12.46 vs. 54.52 -/+ 12.37, p = 0.0002), lower levels of Hb (99.53 -/+ 14.97 vs. 111.86 -/+ 10.38 g/l, p = 0.0000), creatinine (835.88 -/+ 179.84 vs. 1069.98 -/+ 821.23-/+mol/l, p = 0.0047), albumin (36.58 -/+ 3.41 vs.40.32 -/+ 2.82 g/l, p = 0.0000), cholesterol (4.32 -/+ 1.04 vs. 4.75 -/+ 1.09 mmol/l, p = 0.0025) and higher levels of fibrinogen (4.94 -/+ 1.18 vs. 4.29-/+0.91g/l, p=0.0000) and CRP (30.42-/+29.47 vs. 5.24-/+4.89 mg/l, p=0.0000). The Kaplan-Meier analysis showed that, irrespective of the absence or presence of inflammation and malnutrition, the all-cause mortality was higher in patients with Hb <110g/l (Log-Rank, p=0.00147; p=0.00222). On the other hand, Kaplan-Meier showed that, irrespective of the absence or presence of anaemia (Hb > 110g/l and Hb < 110g/l), the all-cause mortality was higher in patients with the presence of inflammation and malnutrition (Log-Rank, p=0.00222; p=0.00263). The Cox proportional hazard analysis, adjusting for age, showed that only lower serum levels of Hb and higher CRP were associated with all-cause mortality (chi-square=110,306, p=0.0000). Our findings confirm the association of Hb levels < 110g/L with higher mortality among maintenance HD patients, especially in patients with the presence of inflammation and malnutrition. Further investigation of the relationships among anaemia, inflammation and malnutrition and survival is warranted.
尽管近年来血液透析（HD）患者的贫血管理有所改善，但仍有许多患者的血红蛋白（Hb）水平低于当前建议值。由此导致的贫血可能是营养不良与炎症之间的联系之一，也是HD患者死亡率较高的原因之一。本研究的目的是确定HD患者的Hb水平与预后之间的关系，并考虑炎症和营养不良因素。我们回顾性分析了2003年1月至2005年12月期间接受HD治疗的236例患者，根据是否存在炎症和营养不良进行分类（定义为血清白蛋白水平<40 g/L且CRP>8mg/l）。每月测量血清Hb、铁蛋白、肌酐、胆固醇、甘油三酯、高密度脂蛋白胆固醇（HDL）、低密度脂蛋白胆固醇（LDL）、白蛋白和CRP水平，每三个月测量一次纤维蛋白原水平。在三年期间，236例患者中有73例（30%）死亡，大多数死于心血管疾病（62%）。存在炎症和营养不良（44%的患者）与年龄较大有关（60.69 -/+ 12.46岁 vs. 54.52 -/+ 12.37岁，p = 0.0002），Hb水平较低（99.53 -/+ 14.97 vs. 111.86 -/+ 10.38 g/l，p = 0.0000），肌酐水平较低（835.88 -/+ 179.84 vs. 1069.98 -/+ 821.23 -/+mol/l，p = 0.0047），白蛋白水平较低（36.58 -/+ 3.41 vs.40.32 -/+ 2.82 g/l，p = 0.0000），胆固醇水平较低（4.32 -/+ 1.04 vs. 4.75 -/+ 1.09 mmol/l，p = 0.0025），纤维蛋白原水平较高（4.94 -/+ 1.18 vs. 4.29 -/+ 0.91g/l，p = 0.0000）和CRP水平较高（30.42 -/+ 29.47 vs. 5.24 -/+ 4.89 mg/l，p = 0.0000）。Kaplan-Meier分析表明，无论是否存在炎症和营养不良，Hb<110g/l的患者全因死亡率更高（对数秩检验，p = 0.00147；p = 0.00222）。另一方面，Kaplan-Meier分析表明，无论是否存在贫血（Hb > 110g/l和Hb < 1(10g/l)，存在炎症和营养不良的患者全因死亡率更高（对数秩检验，p = 0.00222；p = 0.00263）。Cox比例风险分析在调整年龄后显示，只有较低的血清Hb水平和较高的CRP水平与全因死亡率相关（卡方=110,306，p = (0.0000)。我们的研究结果证实，维持性HD患者中Hb水平<110g/L与较高的死亡率相关，尤其是在存在炎症和营养不良的患者中。有必要进一步研究贫血、炎症和营养不良与生存之间的关系。
