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不同血清磷水平对综合性医院住院患者和慢性肾脏病患者死亡率的影响(肾脏组稿)
Impacts of serum phosphate on mortality in hospitalized patients and patients with chronic kidney disease in a general hospital
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DOI:
作者:
耿雪梅,王一梅,章晓燕,徐夏莲,林静,胡家昌,贾平,谢烨卿,於佳伟,滕杰,丁小强
Geng Xuemei,Wang Yimei,Zhang Xiaoyan,Xu Xialian,Lin Jing,Hu Jiachang,Jia Ping,Xie Yeqing,Yu Jiawei,Teng Jie,Ding Xiaoqiang
作者单位:
复旦大学上海医学院附属中山医院肾内科,上海市肾病与透析研究所,上海市肾脏疾病与血液净化重点实验室
Department of Nephrology, Zhongshan Hospital, Fudan University; Shanghai Institute of kidney and Dialysis; Shanghai Key Laboratory of kidney and Blood Purification, Shanghai 200032, China
关键词:
高磷血症;低磷血症;血清磷;住院患者;慢性肾脏病;死亡率
Hyperphosphatemia; Hypophosphatemia; Serum phosphate; Hospitalized patients; Chronic kidney disease; Mortality
摘要:
目的 探讨住院患者血清磷水平对住院患者和慢性肾脏病(CKD)患者死亡率的影响。方法 收集2014年10月1日至2015年9月30日复旦大学附属中山医院所有住院患者入院时的血清磷水平和临床资料(年龄、性别、身高、体重、合并症、血常规、尿常规、肝肾功能、电解质、血糖、院内死亡、死亡原因等)。按照血清磷水平将其分成6组,采用logistic回归分析影响住院患者和慢性肾脏病患者死亡的危险因素。结果 排除42061例未检测血清磷水平的患者,最终共纳入57786例患者,低磷血症(< 0.80mmol/L)和高磷血症(>1.45mmol/L)的发病率分别为6.5%和6.6%。按照血清磷水平分成6组:≤0.46mmol/L(367例,0.63%)、0.47~0.79mmol/L((3408例,5.90%)、0.80~1.12mmol/L(25256例,43.71%)、1.13~1.45mmol/L(24942例,43.16%)、1.46~1.78mmol/L(3009例,5.21%)以及≥1.79mmol/L(804例,1.39%)。以死亡率最低(0.69%)的1.13~1.45mmol/L组为对照,校正年龄、性别、收缩压、舒张压、空腹血糖、白蛋白、血红蛋白、白细胞、eGFR、合并疾病(高血压、糖尿病、冠心病、恶性肿瘤、脑卒中、肝硬化、心力衰竭、慢性肾脏病、急性肾损伤)以及电解质(血钠、血钾、血氯、血钙、血镁)后,血清磷≤0.46mmol/L组(OR=3.071,95%CI为1.797~5.247)、0.47~0.79 mmol/L组(OR=1.900,95%CI为1.410~2.561)、0.80~1.12mmol/L组(OR=1.319,95%CI为1.056~1.648)和≥1.79mmol/L组(OR=2.292,95%CI为1.470~3.574)的死亡风险均显著高于对照组,而高磷血症中的血清磷1.46~1.78mmol/L(OR=1.144,95%CI为0.755~1.736)并不与住院患者死亡率独立相关。对住院患者中检测血清磷水平的11392例慢性肾脏病患者进行同样的分组,多因素 logistic回归分析提示血清磷<0.80mmol/L、0.80~1.12mmol/L和≥1.79mmol/L仍是慢性肾脏病患者死亡的独立危险因素。结论 住院患者中血磷异常较为常见,低磷血症和严重的高磷血症是住院患者和慢性肾脏病患者死亡的独立危险因素。
Objective The aim of this study was to explore the relationship between serum phosphate concentrations and mortality in hospitalized patients and patients with chronic kidney disease. Methods and patients All admissions to zhongshan hospital, Fudan University from October 1, 2014 to September 30, 2015 were screened. Admission serum phosphate from each unique patient and relevant clinical data were extracted from the institutional electronic database. A multivariable logistic regression model was applied to assess the association between serum phosphate levels and in-hospital mortality in hospitalized patients and patients with chronic kidney disease. Results 99,847 subjects were screened for the study. After excluding 42,061 patients without phosphate concentrations available from laboratory reports on hospital entry, 57,786 patients were included in the analysis. Hypophosphatemia (serum phosphate level was less than 0.80mmol/L) was found in 3775 patients (6.5%) and hyperphosphatemia (serum phosphate level was higher than 1.45mmol/L) was noted in 3813 patients (6.6%). Distribution of phosphate levels was as follows: 0.46mmol/L or less(367 patients, 0.63%),0.47 to 0.79mmol/L(3408 patients, 5.90%), 0.80 to 1.12mmol/L(25256 patients, 43.71%), 1.13 to 1.45mmol/L(24942 patients, 43.16%), 1.46 to 1.78mmol/L(3009 patients, 5.21%),1.79mmol/L or higher(804 patients,1.39%). The lowest in-hospital mortality (0.69%) occurred in patients with phosphate levels between 1.13 and 1.45mmol/L which was defined as a reference group. Adjusting for age, sex, systolic blood pressure, diastolic blood pressure, fasting blood glucose, albumin, hemoglobin, white blood cells, eGFR, comorbidity (including hypertension, diabetes mellitus, coronary disease, malignancy, stroke, liver cirrhosis, heart failure, chronic kidney disease and acute kidney injury) and admission electrolytes (including serum sodium, potassium, chlorine, calcium, magnesium),the results revealed that there was significantly higher death risk than the reference group in phosphate level of 0.46mmol/L or less(OR=3.071,95%CI=1.797~5.247),0.47 to 0.79mmol/L(OR=1.900,95%CI=1.410~2.561), 0.80 to 1.12mmol/L(OR=1.319, 95%CI=1.056~1.648) and 1.79mmol/L or higher(OR=2.292,95%CI=1.470~3.574). A phosphate level of 1.46 to 1.78mmol/L(OR=1.144, 95%CI=0.755~1.736)was not independently associated with in-hospital mortality in hospitalized patients. In 11392 patients with chronic kidney disease, hypophosphatemia, low-normal phosphate (0.80 to 1.12mmol/L) and the phosphate level of 1.79mmol/L or higher were still independent risk factors of mortality. However, the phosphate level of 1.46 to 1.78mmol/L was not independently associated with mortality in patients with chronic kidney disease. Conclusion Dysphosphatemia in hospitalized patients is common. Hypophosphatemia and severe hyperphosphatemia are independent risk factors in hospitalized patients and patients with chronic kidney disease.
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