低成本腹膜透析治疗方案的探讨

摘要

目的 探讨用低成本方案对经济困难的患者行维持性腹膜透析治疗的可能性.方法 回顾性分析西安交通大学医学院第一附属医院腹膜透析中心12例因经济困难行小剂量(＜4 000 ml/d＝腹膜透析的患者,调查患者透析12个月时每周尿素清除率(Kt/V)、每日蛋白摄入量(DPI)、每日热量总摄入量(TDEI)(饮食中每日热量摄入量与每日腹透液吸收葡萄糖产生的热量之和),同时调查患者平均医疗费用情况,用MDRD公式计算患者进入透析时的肾小球滤过率(GFR).用主观全面营养评估法(SGA)评估患者的营养状况,用karnofsky活动指数评分评价患者的活动能力.比较透析12个月与透析开始时血清清蛋白、血红蛋白、康复状况、营养状况,并调查透析12个月时的治疗费用.结果 12例患者进入透析时的GFR为(5.2±1.6)ml/min,12个月后GFR为(1.4±1.1)ml/min(P＜0.01＝,平均 DPI由(0.97±0.42) g·kg-1·d-1降至(0.65±0.12) g·kg-1·d-1(P＜0.05＝,总DEI由(21.3±2.0)kcal·kg-1·d-1升高至(25.4±3.7)kcal·kg-1·d-1(P＜0.05＝,平均残肾Kt/V由(0.98±0.45)降至(0.43±0.30)(P＜0.01＝,平均总Kt/V由(1.72±0.84)降至(1.35±0.41)(P＜0.05＝.透析9个月时血红蛋白由(78.6±19.4)g/d升高至(101.8±27.5)g/L(P＜0.01＝,血清清蛋白由(33.6±7.6)g/L升高至(36.1±10.4)g/L,血尿素氮由(34.0±8.2)mmol/L降至(28.4±9.4)mmol/L(P＜0.05＝,血肌酐由(823.7±146.4)μmol/L降至(762.0±192.6)μmol/L(P＜0.05＝.但12个月时血红蛋白再次降至(88.6±28.7)g/L,仍高于开始透析时(P＜0.05＝,清蛋白降至(33.6±7.6)g/L,血尿素氮再次升高至(32.6±7.7)mmol/L,与开始透析时比较差异均无统计学意义(P＞0.05),肌酐升高至(1 025.5±233.1)μmol/L,高于开始透析时的水平(P＜0.01＝.治疗12个月时,平均透析液浓度较开始透析时明显升高 (P＜0.05＝,平均动脉压由(107.2±92.9)mm Hg降至(103.5±17.8)mm Hg(P＜0.05＝.仅3例患者出现下肢轻度水肿,1例患者出现心衰.SGA评估营养不良的发生率由8/12降低为4/12(P＜0.05＝.治疗12个月时,6例患者康复情况良好,每月平均医疗费用为(2 833.3±1 040 8)元.结论 在保证能量摄入的基础上,给予低蛋白饮食,同时减少透析剂量可最大限度地降低医疗费用.透析早期,严格的水盐控制可避免产生容量超负荷,饮食调整及一些非药物治疗都有利于患者节省开支,提高患者的社会回归状况.但随着残肾功能的丧失,如果透析剂量不能逐渐增加,可能会出现毒素蓄积,营养不良,活动能力减退,水负荷增多的现象.%Objective To explore the possibility of the most economical way of sustained peritoneal dialysis ( PD ) prescription for poor patients. Methods Twelve patients received low dose PD ( ＜4000 ml/d ) due to poor economic status from our hospital were studied retrospectively. Kt/V, DPI, TDEI, and average cost were investigated. MDRD formula was applied to calculate the baseline GFR and subjective global assessment ( SGA ) was employed to access the nutritious status of the patients. Karnofsky performance score was used to evaluate the physical activity. Serum albumin, hemoglobulin, rehabilitation status and nutritious status were compared at baseline and 12 months after PD treatment. Results Glomeruar filtration rate was ( 5. 2 ± 1. 6 ) ml/min at the start of dialysis and declined to ( 1. 4 ± 1. 1 ) ml/min after 12 months of PD ( P ＜0. 01 ). After 1 yearofPD, average DPI declined from ( 0. 97 ± 0. 42 ) g · kg-1· d-1 to ( 0. 65 ±0. 12 ) g · kg-1 · d-1 (P＜0.05), DEI increased from ( 21. 3 ±2. 0 ) kcal · kg-1 · d-1 to ( 25. 4 ±3. 7 ) kcal· kg-1 · d-1 ( P ＜0. 05 ), average current total Kt/V decreased from ( 1. 72 ±0. 84 ) to ( 1. 35 ±0. 41 ) ( P ＜0. 05 ), and urine Kt/v dropped from ( 0. 98 ±0. 45 ) to ( 0. 43 ±0. 30 ) ( P ＜ 0. 01 ). After 9 months of PD treatment, hemoglobin levels increased from ( 78. 6 ± 19. 4 ) g/d to ( 101. 8 ± 27. 5 ) g/L ( P ＜ 0. 01 ), serum albumin increased from ( 33. 6 ± 7. 6 ) g/L to ( 36. 1 ± 10. 4 ) g/L, levels of serum urea decreased from ( 34. 0 ± 8. 2 ) mmol/L to ( 28. 4 ± 9. 4 ) mmol/L ( P ＜ 0. 05 ), and serum creatinine levels dropped from ( 823. 7 ± 146. 4 ) μmol/L to ( 762. 0 ± 192. 6 ) μmol/L ( P ＜ 0. 05 ). After 12 months of PD, hemoglobin levels dropped to ( 88. 6 ± 28. 7 ) g/L, still higher than baseline though ( P ＜0. 05 ); serum albumin levels dropped to ( 33. 2 ± 8. 0 ) g/L; serum urea increased to ( 32. 6 ±1.1 ) mmol/L, similar to baseline ( P ＞0. 05 ); creatinine levels increased to ( 1 025. 5 ± 233. 1 ) μmol/L, higher than baseline ( P ＜0. 01 ). The glucose concentration of dialysate increased with volume overload on dialysis ( P ＜0. 05 ). Only 25% patients suffered mild leg edema and one case developed heart failure. Mean arterial pressure declined from ( 107. 2 ± 92. 9 ) mm Hg to ( 103. 5 ± 17. 8 ) mm Hg ( P ＜0. 05 ). The prevalence of malnutrition by SGA decreased from 8/12 to 4/12 ( P ＜0. 05 ). Acceptable rehabilitation status was observed in 6 cases. The mean cost for therapy was ( 2 833. 3 ± 1 040. 8 ) Yuan per month. Conclusion Low dose of peritoneal dialysis combined with low protein intake on the basis of sufficient high -energy supplement maximally decreases the cost of therapy. During the early stage of dialysis, fluid and salt restriction, low protein diet and certain non - medical methods are beneficial to cost - saving and would improve the clinical outcome. However, as the residual renal function declines, toxin accumulation, malnutrition, loss of physical activity and volume overload status due to inadequacy of dialysis might finally occur.