不同基本医疗保障维持性血液透析患者营养不良及炎症状态关系

摘要

目的：观察不同基本医疗保障下维持性血液透析（MHD）患者营养不良发生情况及炎症状态，并探讨两者的关系。方法维持性血液透析患者120例，按医保支付比例不同将患者分为城保组80例和非城保组（农保）40例。采用主观整体评估法（ SGA）对营养不良发生率进行评定；比较不同医保组的人体测量学指标，血清白蛋白、前白蛋白、转铁蛋白、血红蛋白、尿素氮、肌酐及尿素清除指数（Kt / V）；检测血清超敏 C 反应蛋白（ hs - CRP）、白细胞介素-6（IL -6）、肿瘤坏死因子α（TNF -α）水平，分析 CRP 水平与营养不良相关指标的关系。结果城保组的营养不良发生率为30%，非城保组为70%，2组比较有显著性差异（ P ﹤0.01）。城保组的营养相关指标比非城保组显著升高（P ﹤0.05），城保组、非城保组的慢性炎症标志物高于正常对照（P 均﹤0.05），但2组间炎症因子比较无显著性差异（ P ﹥0.05）。非城保组透析前、后 IL -6均显著高于城保组（P ﹤0.05）；CRP 升高组白蛋白、转铁蛋白、血红蛋白水平明显低于 CRP 正常组（ P ﹤0.05或0.01），SGA 评分明显高于 CRP 正常组（ P ﹤0.01）。结论不同医保下维持血液透析营养不良发生率不同，非城保MHD 患者营养不良发生率显著高于城保组，其营养状况更差。MHD 患者营养不良者均存在微炎症反应，MHD 患者营养不良与炎症反应有相关性，营养不良与 CRP 成正相关，即营养不良的程度越严重，CRP 值就越高。CRP 反应蛋白是反映维持性血液透析患者微炎症反应较好的预测指标，MHD 患者营养不良中血清 IL -6有较高水平，微炎症反应对血透患者营养不良有重要的影响。%Objective It is to observe the malnutrition incidence and the inflammation state of patients with maintenance hemodialysis(MHD)for different basic medical insurance,and approach the relationship of them. Methods 120 patients with MHD were divided into city insurance group(80 cases)and not city insurance group(40 cases)according to the different medical insurance payment ratio. The incidence of malnutrition were assessed by subjective global assessment method(SGA);the anthropometry index,serum albumin,prealbumin,transferrin,hemoglobin,urea nitrogen,creatinine,urea clearance in-dex(Kt / V)in different medical insurance were compared;the levels of serum hypersensitive C - reactive protein( hs -CRP),interleukin - 6(IL - 6)and tumor necrosis factor - α(TNF - α)were detected,and the relationship between the lev-el of hs - CRP and the relevant indicators of malnutrition were analyzed. Results The incidence of malnutrition was 30% in city insurance group and 70% in not city insurance group,there was significant difference between the two groups(P ﹤ 0. 01). The nutrition index of city insurance group was markedly higher than that of not city insurance group(P ﹤ 0. 05). The chronic inflammatory markers of city insurance group and not city insurance group were markedly higher than that of normal controls (all P ﹤ 0. 05),but there was no significant difference between the two groups(P ﹥ 0. 05). The IL - 6 levels in not city in-surance group before and after dialysis were significantly higher than that in city insurance group(P ﹤ 0. 05);the levels of al-bumin,transferrin and hemoglobin of elevated CRP group was markedly lower than that of normal CRP group( P ﹤ 0. 05 or 0. 01),and the SGA score was markedly higher than that of normal CRP group( P ﹤ 0. 01). Conclusion The incidences of malnutrition for MHD under different medical insurance are different,the incidences of not city insurance group is markedly higher than that of city insurance group,and with poor nutritional status. Micro inflammation is existed in all patients with MHD malnutrition,malnutrition in patients with MHD has correlation with inflammation,and malnutrition is positively relatedwith CRP,namely,more serious of malnutrition degree,the CRP value is higher. CRP is a better indicator of in patients with MHD,the serum IL - 6 have higher levels in MHD patients of malnutrition,micro inflammatory reaction plays an important in-fluence in MHD patients with malnutrition.