摘要/Abstract

摘要： 目的·探究行维持性血液透析终末期肾病（end-stage renal disease，ESRD）患者脑部结构性异常和认知功能变化特点，分析可能影响其神经系统结构和功能异常的相关因素。方法·选取于上海交通大学医学院附属第九人民医院进行维持性血液透析治疗的ESRD患者37例，所有患者既往均无脑卒中史。对入选患者进行颅脑磁共振成像（magnetic resonance imaging，MRI）平扫和简易精神状态量表（Mini-Mental State Examination，MMSE）评价。根据MRI结果分为腔隙性脑梗死患病组（n=33）和对照组（n=4），或者分为脑白质高信号患病组（n=14）和对照组（n=23）。采用t检验、Mann-Whitney U检验、χ2检验及Fisher精确检验比较患病组和相应对照组在人口学特征、既往病史、血液指标、透析充分性等方面的差异，采用Spearman相关性分析研究临床特征、脑结构性异常与认知功能间的相关性。结果·37例患者中，男性19例、女性18例，平均年龄（59.4±12.3）岁。腔隙性脑梗死和脑白质高信号发生率分别为89.2%和37.8%，24.3%的患者存在认知损害。腔隙性脑梗死患者年龄较大，血红蛋白、红细胞比容、血清白蛋白、总蛋白水平较低，甲状旁腺素、红细胞沉降率、肿瘤坏死因子α、白介素-6水平较高。脑白质高信号患者年龄较大，转铁蛋白饱和度较低，甲状旁腺素水平较高，且差异具有统计学意义（均P<0.05）。相关性分析结果显示，MMSE 总分与年龄负相关（r=-0.471，P=0.003），与受教育程度（r=0.355，P=0.031）、高血压史（r=0.358，P=0.030）正相关。研究未发现腔隙性脑梗死或脑白质高信号与MMSE总分之间的关联，但回忆力与腔隙性脑梗死存在一定程度负相关（r=-0.357，P=0.030）。结论·行维持性血液透析ESRD患者脑血管病变及认知损害发生率较高，高龄、贫血、炎症状态、慢性肾脏病矿物质和骨异常等可能是血液透析患者出现脑结构性异常及认知损害的影响因素。
关键词: 终末期肾病, 维持性血液透析, 颅脑磁共振成像, 腔隙性脑梗死, 脑白质高信号, 认知损害
Abstract:
Objective · To explore the patterns of cerebral structural abnormalities and cognitive function alterations in end-stage renal disease (ESRD) patients undergoing maintenance hemodialysis, and the underlying correlative factors. Methods · Thirty-seven ESRD patients undergoing maintenance hemodialysis without prior stroke in Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine were selected. All patients underwent brain magnetic resonance imaging (MRI) and assessment of cognitive function by using Mini-Mental State Examination (MMSE). Patients were divided into lacunar infarction group (n=33) and non-lacunar infarction group (n=4), or white matter hyperintensities (WMH) group (n=14) and non-WMH group (n=23). The difference of demographic characteristics, past history, blood parameter and dialysis adequacy between patients and their controls were analyzed by t test, Mann-Whitney U test, χ2 test and Fisher exact test. Spearman correlation analysis were performed to explore the relationship between clinical features, cerebral structural abnormalities and cognitive function. Results · Nineteen male and eighteen female patients participated in the study. The mean age was (59.4±12.3) years. The incidences of lacunar infarction and WMH were 89.2% and 37.8%, respectively. 24.3% of the participants were diagnosed as cognitive impairment. Patients with lacunar infarction were elder, who had lower level of hemoglobin, hematocrit, serum albumin and serum total protein, while parathyroid hormone (PTH), erythrocyte sedimentation rate, tumor necrosis factor-α and interleukin-6 were elevated. Patients with WMH were also significantly elder, lower in transferrin saturation and higher in PTH. The differences between the two groups were statistically significant (all P<0.05). Spearman correlation analysis showed MMSE score had a negative correlation with age (r=?0.471, P=0.003) and had positive correlations with education status (r=0.355, P=0.031) and hypertension (r=0.358, P=0.030). The study did not find the relationship among lacunar infarction, WMH and MMSE score; however, recall function was found negatively correlated with lacunar infarction (r=?0.357, P=0.030). Conclusion · ESRD patients undergoing maintenance hemodialysis have a high prevalence of cerebrovascular disease and cognitive impairment. Older age, anemia, inflammation status, chronic kidney disease-mineral and bone disorder may be the influencing factors of the cerebral structural abnormalities and cognition decline.
Key words: end-stage renal disease (ESRD), maintenance hemodialysis, brain magnetic resonance imaging, lacunar infarction, white matter hyperintensities (WMH), cognitive impairment


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