【作者】 高红；

【导师】 刘春安；

【作者基本信息】 泰山医学院 ， 内科学， 2011， 硕士

【摘要】 目的近年来,随着血液透析、腹膜透析技术的提高,慢性肾功能衰竭(CRF)患者的生存期得到显著延长。但是越来越多的研究发现,CRF特别是尿毒症期患者恶性肿瘤的发病率较高,是正常人群的数倍。恶性肿瘤的发生严重影响了CRF患者的生存时间和生活质量,但是对于CRF病人并发恶性肿瘤的高危因素尚未完全阐明,所以进一步探索这个问题是目前医学界急需解决的重要问题。CRF尿毒症期患者肿瘤发病率增高已经被国内外学者所认可,但目前国内对于CRF氮质血症期患者并发恶性肿瘤的危险性及其相关因素尚无流行病学调查分析。本研究希望通过进一步探索CRF不同时期病人(氮质血症期与尿毒症期)并发恶性肿瘤的危险性、恶性肿瘤发生的危险因素及肿瘤的发病类型,为临床医生进行肿瘤监控提供理论依据,以期对并发肿瘤的CRF患者进行早期发现,早期干预,从而降低患者病死率,延长病人生存期,提高其生活质量。方法选择临床资料完整的慢性肾功能衰竭(排除由恶性肿瘤引起的慢性肾功能衰竭和进行肾移植术的慢性肾功能衰竭)患者609例,其中氮质血症期患者304例,尿毒症期患者305例。对入选的病例进行回顾性分析总结,每例入选患者均记录其一般资料如年龄、性别、原发病(原发性肾小球肾炎、糖尿病肾病、高血压肾病、狼疮性肾炎、梗阻性肾病、马兜铃酸性肾病、镇痛剂肾病、慢性肾盂肾炎、慢性尿酸性肾病、多囊肾等)、伴发病(乙型肝炎、丙型肝炎、获得性肾囊肿病等)、血肌酐(Cr)、血尿素氮(BUN)、肾小球滤过率(GFR)、体重指数(BMI),血清白蛋白(ALB)、血红蛋白(Hb),尿毒症患者需记录透析方式、透析龄。如有肿瘤,上述指标均取自发现肿瘤时,并记录肿瘤的发病类型。所有计量资料均采用均数±标准差的方式表示,率的比较用χ2检验,组间比较采用t检验,肿瘤相关因素的分析采用Logistic回归分析。所有统计方法均采用SPSS15.0统计软件进行。结果1、氮质血症期和尿毒症期两组患者的一般情况氮质血症期恶性肿瘤发病率1.32%;尿毒症期恶性肿瘤发病率4.26%,CRF患者总体发病率2.79%,尿毒症期患者恶性肿瘤发病率高于氮质血症期患者,两者差异有统计学意义(P<0.05)。血液透析患者恶性肿瘤发病率为6.38%,腹膜透析患者恶性肿瘤发病率为0.8%,血液透析患者的肿瘤发病率高于腹膜透析患者,两者差异有统计学意义(P<0.05)。2、氮质血症期和尿毒症期两组患者恶性患者肿瘤发生情况17例恶性肿瘤患者中,以泌尿系统肿瘤发生率最高,共7例,占41.2%,其次为消化系统肿瘤,共5例,占29.4%。17例恶性肿瘤患者,平均年龄(64.50±12.35)岁。透析龄平均为(60.61±32.46)月,肾小球滤过率为(15.62±8.74)ml/min。非肿瘤患者共592例,平均年龄(50.15±12.80)岁,透析龄平均为(50.32±24.46)月,肾小球滤过率为(34.67±15.82)ml/min。肿瘤患者的年龄、透析龄比非肿瘤患者长,差别具有统计学意义(P<0.05)。肿瘤患者的肾小球滤过率低于非肿瘤患者,差别具有统计学意义(P<0.05)。3、CRF患者的原发病、伴发病及肿瘤发病率在并发恶性肿瘤CRF患者的原发病中,马兜铃酸肾病患者中肿瘤发病率占27.27%,镇痛剂肾病为8.33%,慢性肾小球肾炎为3.66%,高血压肾病为2.86%,糖尿病肾病为1.72%,不同原发病的肿瘤发病率差别有统计学意义(P<0.01)。609例CRF患者中,获得性肾囊肿病81例,发病率是13.31%。其中2例发生肾细胞癌,肿瘤发生率为2.47%。4、CRF患者恶性肿瘤发生的危险因素分析用Logistic回归分析后,结果显示高龄、透析龄长、肾小球滤过率下降是恶性肿瘤发生的危险因素。5、并发肿瘤患者的治疗与预后情况305例尿毒症透析患者在随访期间死亡例数为65例,其中死亡原因分别为:心血管疾病19例(29.2%),脑血管疾病14例(21.6%),感染9例(13.8%),全身衰竭8例(12.3%),肿瘤6例(9.3%),其他9例(13.8%)。肿瘤是导致透析患者死亡的第五位原因。结论1、尿毒症期患者恶性肿瘤的发病率高于氮质血症期患者。=2、血液透析患者比腹膜透析患者的肿瘤发病率高。3、原发病为马兜铃酸肾病的CRF患者恶性肿瘤发病率高于其他原发病引起的CRF患者。4、患者的年龄、透析龄和肾小球滤过率是恶性肿瘤发生的危险因素,高龄、透析龄长的CRF患者发生恶性肿瘤的危险性更高,随着肾小球滤过率的下降,恶性肿瘤的危险性也增加。5、CRF患者伴发的恶性肿瘤中泌尿系统肿瘤占41.2%,居首位,其次为消化系统肿瘤,占29.4%。6、恶性肿瘤是导致透析患者死亡的第五位原因。更多还原

【Abstract】 ObjectiveIn recent years, with hemodialysis and peritoneal dialysis technology improved, the survival of patients with chronic renal failure (CRF) has significantly extended. But more and more studies have found that the incidence of cancer in patients with CRF particular in uremia is several times than the normal population. The high incidence of malignant tumors in patients with CRF has a serious impact on their survival time and quality of life, but the risk factors for malignancy has not been fully clarified. So exploring this question is the urgent need to address important medical problems. Patients with CRF in uremia having a higher incidence of tumors have been recognized by scholars. But up to now, the risk of cancer and related factors for the patients with CRF in azotemia is not yet epidemiological survey analysis. This study was to further explore the different periods of patients with CRF (azotemia and uremia) about the risk of malignancy, cancer risk factors and the incidence of tumor type, tumor control for clinicians to provide a theoretical basis. We hope to early detect and early intervene so as to reduce the mortality and prolong patient survival time and improve their quality of life for patients with malignancies.MethodsSelect complete clinical data of 609 patients with chronic renal failure cases(rule out the patients caused by malignancy).Including 304 cases of patients with azotemia, uremia patients 305,Of the selected cases were retrospectively analyzed and summarized, each case selected will be recorded by the general information such as age,gender,primary disease(such as Primary glomerulonephritis, Diabetic nephropathy, Hypertensive nephropathy, Lupus nephritis,obstructive nephropathy,Aristolochic acid nephropathy,Analgesic nephropathy,Chronic pyelonephritis,Chronic uric acid nephropathy,Polycystic kidney disease,etc.) Comorbidity(epatitis B, hepatitis C, acquired renal cystic disease, etc.),Serum creatinine (Cr), blood urea nitrogen (BUN), glomerular filtration rate (GFR), body mass index (BMI), serum albumin (ALB), hemoglobin (Hb).The patients with Uremia are required to record dialysis modality and dialysis age. If the tumors were detected, all these indicators above mentioned are derived from the moment of diagnosing the tumor,and record the tumor types. All measurement data are recorded by ( x±s) means thatRates compared by X2 test,Between groups using t test.Tumor-related factors were analyzed by Logistic regression analysis.All statistical methods were conducted using statistical software SPSS15.0.Results1.Azotemia and uremia on the general situation of two groups of patients. The cancer incidences in the stage of the azotemia and uremia were 1.32% and 4.26% respectively.The overall incidence of patients with CRF was 2.79%,patients in uremic have a higher incidence of cancer than patients in azotemia.The difference was statistically significant(P<0.05). Hemodialysis patients has a 6.38% incidence of malignant tumors,Peritoneal dialysis was 0.8% incidence of malignant tumors,Hemodialysis patients with a high incidence of malignancy in peritoneal dialysis patients , The difference was statistically significant(P<0.05).2.Azotemia and uremia on the tumor situation of two groups of patients.There were 17 cases of malignant tumor patients in azotemia and uremia patients, the highest incidence of urinary system cancer was 41.2%,a total of 7 cases.Followed by digestive system tumors, a total of 5 patients, accounting for 29.4%.Four of them occurred in azotemia were 2 cases of malignant bladder cancer, 1 case of gastric cancer, 1 case of breast cancer.17 cases of malignant tumor patients, average age (64.50±12.35) years.The average duration of dialysis (60.61±32.46) months.The average duration of dialysis (60.61±32.46) months. A total of 592 cases of non-tumor patients, average age (50.15±12.80) years, the average age of dialysis (50.32±24.46) months, glomerular filtration rate (34.67±15.82) ml / min.Cancer patient’s age, duration of dialysis patients than non-tumor length, the difference was statistically significant.Glomerular filtration rate in patients with cancer than non-cancer patients, the difference was statistically significant(P<0.05).3.CRF patients with primary disease,concomitant disease and the tumor incidence. In the original pathogenesis of patients with CRF malignancy,the incidence of tumor in the aristolochic acid nephropathy was 27.27%, accounting for 8.33% in analgesic nephropathy, 3.66% in chronic glomerulonephritis, 2.86% in hypertensive nephropathy, 1.72% in diabetic nephropathy. Tumor incidence was significantly different in different primary disease (P <0.01).609 patients with CRF include 81 cases with acquired renal cystic disease, the incidence rate is 13.31%. in which 2 cases of renal cell carcinoma, tumor incidence was 2.47%.4.CRF patients with the risk factors of cancer Logistic regression analysis showed that age, duration of dialysis age, glomerular filtration rate is the risk factors of the tumors.5.The treatment and prognosis of tumor patients There are 65 patients with uremia and dialysis died during follow-up, in 305 patients with uremia and dialysis. The cause of death were 19 cases of rdiovascular diseas(e29.2%), 14 cases of cerebral vascular disease(21.6%),9 cases of infection(13.8%),8 cases of systemic failure(12.3%),6 cases of tumor(9.3%) ,The other is nine cases(13.8%). Malignancy in dialysis patients leading to the fifth cause of death.Conclusion1. Patients with uremia have a higher incidence of malignant tumors than azotemia.2.Hemodialysis patients have a higher tumor incidence than peritoneal dialysis patients.3.The incidence of malignant tumors has a higher rate in primary disease of aristolochic acid nephropathy in patients with CRF than in other kidney disease.4.The patient’s age, duration of dialysis ages and glomerular filtration rate are the risk factors of malignancy. With the increase of age and dialysis duration,patients with CRF have a higher risk of malignant tumors. Particularly, along with the decline of the glomerular filtration,the risk of cancer will increase.5. Urinary system tumors accounting for 41.2% was the first rank in the patients of CRF with malignancy,followed by digestive system tumors, accounting for 29.4%.6. Malignancy in dialysis patients leading to the fifth cause of death.更多还原