老年维持性血液透析患者认知功能障碍的影响因素及其对脑血流动力学、肠道菌群和预后的影响

摘要 目的：探讨老年维持性血液透析（MHD）患者认知功能障碍（CI）的影响因素及其对脑血流动力学、肠道菌群和预后的影响。方法：选取2017年2月～2021年1月长治医学院附属晋城医院收治的411例老年MHD患者，根据蒙特利尔认知评估量表（MoCA）评分结果，将其分为CI组（n=321）和非CI组（n=90）。收集所有老年MHD患者临床资料，检测、分析其脑血流动力学和肠道菌群水平。采用Logistic回归分析老年MHD患者CI的影响因素。随访18个月，采用Kaplan-Meier法绘制两组患者生存曲线，对比其生存预后情况。结果：411例老年MHD患者CI发生率为78.10％（321/411）。单因素分析显示，CI组年龄大于非CI组，体质指数（BMI）、单室尿素清除指数（spKt/V）、白蛋白水平低于非CI组，受教育年限＞12年比例少于非CI组，透析龄长于非CI组，高血压、糖尿病比例和全段甲状旁腺素高于非CI组（P＜0.05）。多因素Logistic回归分析显示，年龄及透析龄增加和高血压、糖尿病为老年MHD患者CI的独立危险因素，受教育年限＞12年和BMI、spKt/V、白蛋白水平升高为其独立保护因素（P＜0.05）。与非CI组比较，CI组大脑中动脉-平均血流速度（MCA-Vm）、大脑前动脉-平均血流速度（ACA-Vm）降低，大脑中动脉-搏动指数（MCA-PI）、大脑前动脉-搏动指数（ACA-PI）升高（P＜0.05）。与非CI组比较，CI组肠球菌和大肠埃希菌数量增加，乳杆菌和双歧杆菌数量减少（P＜0.05）。Kaplan-Meier生存曲线分析显示，CI组累积生存率低于非CI组（P＜0.05）。结论：年龄、BMI、受教育年限、透析龄、高血压、糖尿病、spKt/V、白蛋白是老年MHD患者CI的影响因素，CI与老年MHD患者脑血流动力学紊乱、肠道菌群失衡和预后不良有关。

Influencing Factors of Cognitive Impairment in Elderly Maintenance Hemodialysis Patients and Their Effects on Cerebral Hemodynamics, Intestinal Flora and Prognosis

ABSTRACT Objective: To investigate the influencing factors of cognitive impairment (CI) in elderly maintenance hemodialysis (MHD) patients and its effects on cerebral hemodynamics, intestinal flora and prognosis. Methods: 411 elderly MHD patients who were admitted to Jincheng Hospital Affiliated to Changzhi Medical College from February 2017 to January 2021 were selected, and they were divided into CI group (n=321) and non-CI group (n=90) according to the score results of Montreal Cognitive Assessment Scale (MoCA). The clinical data of all elderly MHD patients were collected, and their cerebral hemodynamics and intestinal flora were detected and analyzed. Univariate and multivariate Logistic regression were used to analyze the influencing factors of CI in elderly MHD patients. The patients were followed up for 18 months, Kaplan-Meier method was used to draw the survival curves of the two groups. Results: The incidence of CI in 411 elderly MHD patients was 78.10% (321/411). Univariate analysis showed that the age in the CI group was longer than that in the non-CI group, body mass index (BMI), single pool Kt/V (spKt/V), albumin level were lower than those in the non-CI group, the proportion of education years greater than 12 years was lower than that in the non-CI group, dialysis age was longer than that in the non-CI group, the proportion of hypertension, diabetes and total parathyroid hormone were higher than those in the non-CI group (P<0.05). Multivariate Logistic regression analysis showed that the increased of age and dialysis age, hypertension and diabetes were independent risk factors for CI in elderly MHD patients, and the education years greater than 12 years and the increased of BMI, spKt/V and albumin levels were independent protective factors (P<0.05). Compared with the non-CI group, the middle cerebral artery mean blood flow velocity (MCA-Vm) and the arteria cerebri anterior mean blood flow velocity (ACA-Vm) in the CI-group decreased, and the middle cerebral artery pulsatility index (MCA-PI) and the arteria cerebri anterior pulsatility index (ACA-PI) increased(P<0.05). Compared with the non-CI group, the number of enterococcus and Escherichia coli in the CI group increased, while the number of lactobacillus and bifidobacteria decreased (P<0.05). Kaplan-Meier survival curve analysis showed that the cumulative survival rate in the CI group was lower than that in the non-CI group(P<0.05). Conclusion: Age, BMI, education years, dialysis age, hypertension, diabetes, spKt/V and albumin are the influencing factors of CI in elderly MHD patients, and CI is associated with cerebral hemodynamic disorder, intestinal flora imbalance and poor prognosis in elderly MHD patients.