摘要
目的：
本研究旨在了解维持性血液透析患者衰弱现状，分析维持性血液透析患者衰弱的影响因素，根据存在的具体情况提出合理的建议，为制定延缓患者衰弱有效的干预策略提供参考依据。
方法：
应用横断面研究，于2020年5月至10月便利选取医院血液净化中心维持性血液透析患者为研究对象，采用一般资料调查表、FRAIL量表、Charlson合并症指数（CCI）、匹兹堡睡眠指数量表（PSQI）、日常生活能力量表（ADL）、主观综合营养评估（SGA）、医院焦虑抑郁量表（HAD）和社会支持评定量表（SSRS）对研究对象进行测评。采用Epi Data3.1软件建立数据库，运用SPSS23.0软件进行数据分析。采用描述性统计分析、Mann-Whitney u检验、Kruskal-Wallis H检验、Spearman相关性分析和有序多分类Logistics回归分析探索维持性血液透析患者衰弱现状及其影响因素。
结果：
本研究共调查维持性血液透析患者468人，回收有效问卷460份，有效回收率为98.29%。对460例研究对象进行统计分析，结果如下：
1 460例维持性血液透析患者中，无衰弱者146例（31.74%）、衰弱前期者177例（38.48%）、衰弱者137例（29.78%）。衰弱的各指标中疲乏和阻力感发生率较高，分别为48.91%和37.83%。
2单因素分析结果显示：性别、年龄、婚姻状况、文化程度、工作状态、锻炼身体、腹部肥胖、多重用药、原发病、合并其他慢性病（糖尿病、心血管疾病、脑血管疾病、慢性阻塞性肺疾病和癌症）、甲状旁腺激素、血红蛋白、白蛋白、尿素清除指数、不同合并症指数得分和是否存在抑郁与维持性血液透析患者衰弱等级有关，差异有统计学意义（P＜0.05）。
3 Spearman相关性分析结果显示：衰弱中的疾病情况与睡眠质量中的入睡时间、睡眠时间、睡眠障碍、催眠药物和日间功能各维度间不相关（P＞0.05），衰弱总分和其余维度与睡眠质量总分和各维度间均呈正相关（P＜0.05）；衰弱总分及各维度与日常生活能力和主观营养状况总分与各维度间均呈正相关（P＜0.05）,与社会支持总分及各维度间均呈负相关（P＜0.05）。
4 有序多分类Logistic 回归分析结果显示性别、年龄、婚姻状况、甲状旁腺激素、血红蛋白、白蛋白、Charlson 合并症指数、睡眠质量、日常生活能力、主观营养状况、抑郁和社会支持是维持性血液透析患者发生衰弱的独立影响因素（P＜0.05）。
结论：
1 维持性血液透析患者衰弱发生率较高，疲乏是其衰弱的主要表现，提示医护人员应高度重视透析患者疲乏的问题。
2 多因素分析结果显示：性别、年龄、婚姻状况、甲状旁腺激素、血红蛋白、白蛋白、Charlson 合并症指数得分、睡眠质量、日常生活能力、主观营养状况、抑郁和社会支持是维持性血液透析患者衰弱发生的独立影响因素。医疗卫生行业应关注患者上述问题，采取有效的措施，以延缓其衰弱进程，提高患者的生存质量。
关键词： 维持性血液透析；终末期肾病；衰弱；现况调查；影响因素 。
ABSTRACT
Objectives:
To understand the current status of frailty among maintenancehemodialysis patients, in this study, we analyze the influencing factors offrailty. Moreover, related suggestions are put forward based on the specificconditions, aiming to provide a reference for the development of effectiveintervention strategies to delay the frailty of patients.
Methods:
Application of cross-sectional research, A convenience sample ofmaintenance hemodialysis patients was selected from the blood purificationcenter of hospitals from May to October 2020. The general situationquestionnaire, FRAIL scale, CCI, PSQI, ADL, SGA, HAD and SSRS wereused for evaluation. The database was set up with Epi Data3.1, and then wasanalyzed by SPSS 23.0. Descriptive statistical analysis, Mann-Whitney u test,Kruskal-Wallis H test, Spearman rank correlation, and ordinal logisticregressions were utilized to explore the current status of frailty andinfluencing factors among maintenance hemodialysis patients.
Results:
A total of 468 questionnaires were distributed and 460 were effectivelyreceived, with an effective response rate of 98.29%. A statistical analysis of460 research subjects, the results were as follows:
1. Among the 460 maintenance hemodialysis patients, 146 (31.74%)were not frailty, 177 (38.48%) were pre-frailty, and 137 (29.78%) werefrailty. The incidence of fatigue and resistance in the various indicators offrailty were higher, which were 48.91% and 37.83%.
2. Single factor analysis results showed that there were statisticallysignificant differences in gender, age, marital status, education level, work status, physical exercise, abdominal obesity, multi-drug, primary disease,other chronic diseases (diabetes, cardiovascular disease, cerebrovasculardisease, chronic obstructive pulmonary disease and cancer), parathyroidhormone, hemoglobin, albumin , KT/V , the scores of different charlsoncomorbidity Index and whether there was depression are related to the frailtyof maintenance hemodialysis patients (P＜0.05).
3. Correlation analysis results showed that there is no correlationbetween the illness and sleep latency, sleep duration, sleep disturbances, useof sleeping medication and daytime dysfunction (P>0.05), the total frailtyscore and other dimensions were positively correlated with the total scores ofPSQI and each dimension(P＜0.05); The total frailty score and eachdimension were positively correlated with the total scores of ADL and SGAand each dimension (P＜0.05); and there were negative correlations betweenthe total score of SSRS and each dimension (P<0.05).
4. Multivariate analysis showed that there were independent influencingfactors for frailty in gender, age, marital status, parathyroid hormone,hemoglobin, albumin, the scores of different charlson comorbidity Index,sleep quality, activity of daily living, subjective nutritional status, depressionand social support (P＜0.05).
Conclusion:
1. The incidence of frailty in maintenance hemodialysis patients washigher. Fatigue was the main manifestation of frailty. The results suggestedthat medical staff should attach great importance to the problem of fatigue ofdialysis patients.
2. Gender, age, marital status, parathyroid hormone, hemoglobin,albumin, the scores of different charlson comorbidity Index, sleep quality,activity of daily living, subjective nutritional status, depression and socialsupport were the independent influencing factors of frailty amonghemodialysis patients. The medical and health industry should pay attentionto the above issues of patients and take effective measures to delay theirfrailty process and to improve the quality of life of patients.
Keywords: Maintenance hemodialysis; End stage renal disease; Frailty;Current situation survey; Influencing factors。
前言
1、研究背景。
慢性肾脏病(Chronic Kidney Disease，CKD)是世界范围内发展最迅速的非传染性疾病之一，人口老龄化的加剧和代谢性疾病（如肥胖、高血压等）患病率的增加，使得CKD成为本世纪公共卫生面临的最大挑战之一[1]。
2017年全球疾病死亡排名中CKD已由1990年的第17位上升至第12位，全世界共有120万人因该病死亡，到2040年，这一数字预计会达到400万[2]。全球疾病负担研究（Global Burden of Disease Study，GBD）发现，2017年全球CKD的患病率为9.1%，自1990年来增加了29.3%，累计CKD患者6.975亿例[2]。美国CKD患病率为14.2%[3]。欧洲患病率从4.1%~25.5%不等[4]。我国CKD的患病率为12.49%，其中男性12.80%、女性12.59%，华北地区患病率为16.90%[5]。
CKD在高龄和慢性病（如高血压、糖尿病）等高危人群中发病率为36.1%[6]。
CKD被认为是最易被忽视的慢性疾病，发病隐匿，大多数患者一经发现，肾功能已严重受损，已达或即将发展至终末期肾病（End StageRenal Disease，ESRD）阶段，需要进行肾脏替代治疗（Renal ReplacementTherapy，RRT）来维持生命。随着RRT的普遍应用，ESRD患者死亡率逐渐下降。研究显示2015~2030年间，随着ESRD患病率的增加和死亡率下降将使患者数量增加29%~68%，这将给卫生系统带来巨大挑战[7]。
2010年全球接受RRT的人数有261.8万人，预计到2030年将达到543.9万人，且主要集中在亚洲和非洲等发展中地区[8]。目前RRT有血液透析(Hemodialysis，HD)、腹膜透析(Peritoneal Dialysis，PD)和肾移植(RenalTransplantation，RT)三种形式[9]。由于费用高昂、肾脏供体有限、配型成功率低以及缺乏支持移植的基础设施，导致RT的开展受到限制，从而让透析成为世界各地患者最普遍的治疗方式[10]。在透析治疗中，由于HD的安全性和有效率高，使得其成为ESRD最主要的治疗方式。
HD指应用弥散、超滤和对流原理清除体内的代谢废物和多余的水分和电解质，达到净化血液、维持电解质和酸碱平衡的目的[11]。维持性血液透析（Maintenance Hemodialysis，MHD）是所有长期透析患者的主要治疗方式，随着医疗技术的不断发展，HD在我国应用更加广泛。
2017年我国HD患者约合53.28万人，占所有透析患者的92.12%，且每年以9.7%的速率在增加，预计2025年将会达到87.44万人[12-13]。在我国，一年中用于透析的医疗支出为9.11亿元人民币[14]。随着透析设施、技术的发展和医疗观念的更新，患者长期生存率得到明显改善。但由于疾病的不可逆性以及长期创伤性的替代治疗，患者仍存在预期寿命低、并发症多等情况。
CKD会导致慢性炎症、动脉硬化和矿物质代谢紊乱等生理变化，这些变化会直接或间接引起患者发生肌肉减少症[15]。另外MHD治疗会直接损害患者骨骼肌和关节的生理功能，使患者的活动能力降低[16]。因此，在MHD患者中衰弱的存在非常普遍。
衰弱是指由多种原因引起的一种临床综合征，其特征是力量、耐力减退和生理功能下降，从而增加了个体依赖和死亡的易感性[17]。衰弱涉及身体多个系统的改变，随着衰弱程度加重，个体对压力源的抵抗力降低，较小的压力就可能导致机体功能受损[18]。衰弱与多病共存不同，多病共存可以看作个体存在的临床显性疾病的集合，而衰弱则是机体多个生理系统亚临床储备损耗的集合[19]。依据Fried的定义，可以将衰弱的程度分为非衰弱、衰弱前期和衰弱[20]。衰弱被认为是一个动态变化的过程，受到一系列变量的影响，同一个人可能在一段时间内经历不同程度的衰弱，会对人体生理、心理和社会功能产生不同程度的影响。衰弱还会削弱患者的自理能力，诱发意外伤害，同时会增加患者不良结果的发生风险[21]。研究表明，全球老年人衰弱前期和衰弱的发病率为每年1000人中151例和43例，且发生率会因不同性别、地区、收入水平和所使用的诊断标准而发生差异[22]。我国一项包含6个主要地区的流行性调查显示中国社区居住人口衰弱患病率为9.9%，其中北方地区为11.0%[23]。
CKD患者有更高的衰弱风险，衰弱的患病率随着肾功能的下降而增加，在ESRD患者中最高[24]。衰弱与临床众多不良事件相关，衰弱的发生会使患者跌倒、再入院和死亡的风险增大，降低患者的生活质量[25-26]。在MHD患者中及时进行衰弱的识别是指导患者个体化治疗和最大限度提高其预后的必要性措施。
通过查阅文献和相关资料，发现我国对于MHD患者衰弱的研究较少，且不同地区患者患病率差异较大。因此，本研究旨在了解MHD患者衰弱的现况，明确影响患者衰弱的因素，探索改善衰弱的有效措施，为临床实施科学化干预方案提供依据。
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二、国内外研究概述
三、理论基础
四、研究目的与意义
五、技术路线
第二部分 研究对象与方法
一、研究类型
二、研究对象，
(一)抽样方法
(二)纳入标准
(三)排除标准
(四)样本含量.
三、研究指标和工具
四、调查方法
(一)预调查
(二)正式调查.
五、统计学方法.
六、质量控制
(一)研究设计阶段
(二)资料收集阶段
(三)数据录入阶段
七、伦理原则.
第三部分 研究结果
一、维持性血液透析患者的一般资
二、维持性血液透析患者衰弱现状
三、维持性血液透析患者衰弱影响因素的单因素分析.
四、维持性血液透析患者Charlson合并症指数和衰弱的关系
五、维持性血液透析患者睡眠质量和衰弱的关系
六、维持性血液透析患者日常生活能力和衰弱的关系
七、维持性血液透析患者主观营养状况和衰弱的关系.
八、维持性血液透析患者焦忠/抑郁和衰弱的关系
九维持性血液透析患者社会支持和衰弱的关系
十、维持性血液透析患者衰弱影响因素的多因素分析.
第四部分 讨 论
一、维持性血液透析患者的基本特征.
二、维持性血液透析患者衰弱现状分析
三、维持性血液透析患者衰弱的影响因素分析
四、小结
第五部分 结论
1、研究结论。
1.1、 MHD患者衰弱前期和衰弱的发生率都较高，疲乏、阻力感和体重下降是其衰弱的主要表现。临床医务人员应高度关注MHD患者衰弱问题，密切关注疲乏感较重、耐力减退明显和短时间内体重下降较多的患者。
1.2、 MHD患者衰弱程度受性别、年龄、婚姻状况、甲状旁腺激素、血红蛋白、白蛋白、Charlson合并症指数得分、睡眠质量、日常生活能力、主观营养状况、抑郁和社会支持的影响，在临床上应重点关注具有上述特征的人群，实施个性化干预，减少衰弱的发生。
2、创新点。
本研究关注MHD患者衰弱现状，从生理、心理和社会角度对导致患者衰弱的影响因素进行全方面分析。验证了衰弱循环理论在MHD患者人群中的应用，为临床制定衰弱的个体化防治措施提供可靠依据。
3、研究中的局限性。
3.1、本研究的局限性在于仅选择了河北省某二、三级甲等综合性医院血液透析室的患者作为研究对象，后续研究需扩大样本量，进一步深入探究不同地域间MHD患者衰弱现状及其影响因素。
3.2、受时间和条件的限制，本研究采用的是横断面研究，因此不能清楚地分析出衰弱与影响因素之间的因果关系。后续可以进一步采取纵向研究，更清晰地了解影响因素与衰弱之间的关系。
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