李萍,王東紅
有氧運(yùn)動對血液透析患者6分鐘步行距離及血網(wǎng)膜素-1的影響
李萍1,王東紅2△
目的 探討有氧運(yùn)動對維持性血液透析(MHD)患者6分鐘步行距離及血網(wǎng)膜素-1的影響。方法 選取2013年12月—2014年11月天津市第五中心醫(yī)院MHD(MHD組)患者89例,隨機(jī)分為常規(guī)治療組(常規(guī)組,43例)和有氧運(yùn)動治療組(有氧運(yùn)動組,46例),選取50例健康體檢者作為正常對照組(對照組)。有氧運(yùn)動組在常規(guī)治療基礎(chǔ)上進(jìn)行6個(gè)月的透析間期有氧運(yùn)動,常規(guī)組避免任何運(yùn)動干預(yù)。2組MHD患者治療前及治療6個(gè)月后行6分鐘步行試驗(yàn),測量體質(zhì)量、身高及血壓。檢測血網(wǎng)膜素-1、C反應(yīng)蛋白(CRP)、血常規(guī)、血生化,彩色超聲心動測定心血管參數(shù),對6分鐘步行距離(6MWDs)與年齡、CRP、左室射血分?jǐn)?shù)(LVEF)、血網(wǎng)膜素-1間進(jìn)行相關(guān)分析。結(jié)果 MHD組網(wǎng)膜素-1、CRP均較對照組升高,LVEF較對照組下降(均P<0.01);有氧運(yùn)動組經(jīng)有氧運(yùn)動6個(gè)月后,6MWDs、LVEF、血紅蛋白及血網(wǎng)膜素-1較治療前增加,并且6MWDs、LVEF、血紅蛋白較常規(guī)組治療后增加;CRP、空腹血糖、收縮壓較治療前下降,CRP、空腹血糖、收縮壓亦較常規(guī)組治療后下降;治療前MHD患者6MWDs與年齡、CRP呈負(fù)相關(guān),與LVEF、血網(wǎng)膜素-1呈正相關(guān)(r分別為-0.418、-0.229、0.252、0.234,均P<0.05)。結(jié)論 有氧運(yùn)動可明顯增加MHD患者6MWDs、LVEF、血紅蛋白及血網(wǎng)膜素-1,降低CRP、空腹血糖和收縮壓,改善身體活動能力、心功能及微炎癥狀態(tài),從而降低心血管事件的發(fā)生和死亡風(fēng)險(xiǎn)。
腎透析;有氧運(yùn)動;網(wǎng)膜素-1;6分鐘步行試驗(yàn)
血液透析患者具有肌肉萎縮、軀體功能下降、生活質(zhì)量差的特點(diǎn)[1]。身體活動能力差、微炎癥狀態(tài)均與慢性腎臟疾?。–KD)患者心血管疾病高風(fēng)險(xiǎn)相關(guān)。有研究顯示,運(yùn)動能夠改善血液透析患者身體活動能力和微炎癥狀態(tài)[2-4],且網(wǎng)膜素-1與心血管代謝疾病有關(guān)[5]。然而有氧運(yùn)動對維持性血液透析(MHD)患者血網(wǎng)膜素-1的影響國內(nèi)外尚鮮見報(bào)道。筆者對我院MHD患者血網(wǎng)膜素-1變化進(jìn)行了觀察,旨在探討有氧運(yùn)動對MHD患者6分鐘步行距離(6MWDs)及血網(wǎng)膜素-1的影響。
1.1 研究對象 選取我院2013年12月1日—2014年11 月30日MHD患者(MHD組)89例,透析齡≥3個(gè)月,病情穩(wěn)定,排除嚴(yán)重感染、惡性腫瘤、神經(jīng)系統(tǒng)疾病、嚴(yán)重腎性骨病與骨關(guān)節(jié)疾病患者。按照隨機(jī)數(shù)字表法分為常規(guī)治療組(常規(guī)組)43例、有氧運(yùn)動治療組(有氧運(yùn)動組)46例。常規(guī)組中慢性腎小球腎炎21例,糖尿病腎病15例,多囊腎4例,高血壓性腎損害3例。有氧運(yùn)動組中慢性腎小球腎炎24例,糖尿病腎病15例,多囊腎3例,高血壓性腎損害4例。選取同期健康體檢者50例作為正常對照組(對照組),體檢各項(xiàng)指標(biāo)正常,排除腫瘤、感染、結(jié)締組織疾病、心腦血管疾病、糖尿病。
1.2 方法 常規(guī)組與有氧運(yùn)動組予同等條件的血液透析和基礎(chǔ)治療,常規(guī)組避免任何運(yùn)動干預(yù)。有氧運(yùn)動組在常規(guī)組治療基礎(chǔ)上進(jìn)行有氧運(yùn)動干預(yù)。有氧運(yùn)動方式包括散步、爬樓梯、騎自行車、太極拳等,運(yùn)動強(qiáng)度為運(yùn)動時(shí)達(dá)到最大心率(220-年齡)的60%~70%,運(yùn)動時(shí)間為餐后1~2 h,每周3~5次,每次運(yùn)動20~30 min,觀察6個(gè)月。2組MHD患者治療前及治療6個(gè)月后測量6MWDs、體質(zhì)量、身高及血壓。對照組空腹采血,MHD患者治療前及治療6個(gè)月后透析前空腹采血,均10 mL,常規(guī)檢測血常規(guī)、腎功能電解質(zhì)、血糖、C反應(yīng)蛋白(CRP)。其中5 mL于非抗凝真空采血管中室溫靜置30 min后,(4±2)℃2 000~3 000×g離心15 min,留取血清,于-70℃保存。采用酶聯(lián)免疫吸附試驗(yàn)(ELISA)檢測(試劑盒購自美國R&D System公司)網(wǎng)膜素-1。SIEMENS Acuson Antares彩色多普勒超聲檢測左室射血分?jǐn)?shù)(LVEF)。體質(zhì)量指數(shù)(BMI)=體質(zhì)量/身高2(kg/m2)。以簡化的腎臟病改變飲食(MDRD)公式計(jì)算MHD患者腎小球?yàn)V過率(eGFR):eGFR [mL/(min·1.73 m2)]=186×血清肌酐(SCr)-1.154×(年齡)-0.203× (0.742,女性)。
1.3 統(tǒng)計(jì)學(xué)方法 采用SPSS 19.0統(tǒng)計(jì)軟件處理數(shù)據(jù),正態(tài)分布計(jì)量資料以均數(shù)±標(biāo)準(zhǔn)差(±s)表示,實(shí)驗(yàn)前后數(shù)據(jù)比較采用配對t檢驗(yàn),2組間比較采用成組t檢驗(yàn),多組樣本均數(shù)比較采用單因素方差分析,組間多重比較采用LSD-t法;非正態(tài)分布計(jì)量資料采用M(P25,P75)表示,組間比較采用Mann-Whitney U檢驗(yàn);計(jì)數(shù)資料組間比較采用χ2檢驗(yàn),兩因素之間的關(guān)系采用Pearson相關(guān)分析。P<0.05為差異有統(tǒng)計(jì)學(xué)意義。
2.1 3組臨床資料比較 3組年齡、性別、BMI差異均無統(tǒng)計(jì)學(xué)意義;兩患者組血紅蛋白、SCr、eGFR、透析齡、每周透析次數(shù)差異均無統(tǒng)計(jì)學(xué)意義,見表1。
Tab.1 Comparison of clinical characteristics between three groups表1 常規(guī)組、有氧運(yùn)動組與對照組臨床資料比較
2.2 MHD組與對照組血網(wǎng)膜素-1、CRP、LVEF比較 MHD組血網(wǎng)膜素-1、CRP均高于對照組,LVEF低于對照組(P<0.01),見表2。
Tab.2 Comparison of serum levels of omentin-1,CRP and LVEF between MHD patients and healthy controls表2MHD組與對照組血網(wǎng)膜素-1、CRP、LVEF比較
2.3 有氧運(yùn)動對MHD患者6MWDs、LVEF及血網(wǎng)膜素-1等的影響 有氧運(yùn)動組中途退出5例。MHD患者有氧運(yùn)動6個(gè)月后,6MWDs、LVEF、血網(wǎng)膜素-1及血紅蛋白較治療前增加,并且6MWDs、LVEF、血紅蛋白較常規(guī)組治療后增加;CRP、空腹血糖、收縮壓較治療前下降,且較常規(guī)組治療后下降,見表3。
Tab.3 Effects of aerobic exercise on 6MWDs,LVEF and serum level of omentin-1 in MHD patients表3有氧運(yùn)動對MHD患者6MWDs、LVEF及血網(wǎng)膜素-1等的影響 (±s)
Tab.3 Effects of aerobic exercise on 6MWDs,LVEF and serum level of omentin-1 in MHD patients表3有氧運(yùn)動對MHD患者6MWDs、LVEF及血網(wǎng)膜素-1等的影響 (±s)
*P<0.05,**P<0.01;1 mmHg=0.133 kPa
t n LVEF組別常規(guī)組有氧運(yùn)動組t或Z 6MWDs(m)治療前370.1±41.9 371.2±37.7 0.137 Z t 43 41治療后371.2±43.7 393.3±43.3 2.328*1.416 9.302**0.610(0.550,0.670)0.600(0.545,0.675)0.489治療前 治療后0.610(0.570,0.650)0.630(0.600,0.680)2.120*1.189 3.723**CRP(mg/L)治療前5.66±2.46 5.35±2.56 0.563治療后5.26±2.78 4.04±2.24 2.203*1.328 4.058**n組別常規(guī)組有氧運(yùn)動組t t 43 41血紅蛋白(g/L)治療前101.2±17.5 102.9±12.2 0.620網(wǎng)膜素-1(μg/L)治療前62.07±27.55 60.88±26.45 0.201治療后62.24±27.91 66.25±29.90 0.669 t 0.526 3.823**治療后102.1±15.0 108.9±8.8 2.541*t 0.981 8.063**空腹血糖(mmol/L)治療前6.69±3.22 6.44±2.75 0.383治療后6.65±2.66 5.54±2.20 2.080*0.153 4.968**n組別常規(guī)組有氧運(yùn)動組t血鈣(mmol/L)治療前2.33±0.21 2.25±0.20 1.758治療后2.30±0.21 2.21±0.25 1.828 t t t t 43 41 1.559 1.065血磷(mmol/L)治療前2.02±0.57 2.02±0.69 0.022治療后2.05±0.56 1.95±0.60 0.799 1.226 1.912收縮壓(mmHg)治療前140.5±7.9 140.8±10.5 0.144治療后139.5±9.1 134.9±10.2 2.214*0.739 4.854**舒張壓(mmHg)治療前81.6±5.7 81.7±7.3 0.039治療后80.9±7.3 80.6±5.5 0.226 0.543 0.826
2.4 治療前MHD患者6MWDs相關(guān)因素分析 治療前MHD患者6MWDs與年齡(r=-0.418)、CRP (r=-0.229)呈負(fù)相關(guān),與LVEF(r=0.252)、血網(wǎng)膜素-1(r=0.234)呈正相關(guān)(均P<0.05)。
3.1 有氧運(yùn)動對MHD患者身體活動能力、心功能的影響 終末期腎臟疾病患者骨骼肌功能障礙、運(yùn)動耐受性差[6]。尿毒癥患者存在骨骼肌病變,表現(xiàn)為肌肉無力和萎縮,病理學(xué)可見肌纖維壞死、萎縮等[7]。尿毒癥患者肌少癥發(fā)生率高,表現(xiàn)為肌力減退,活動能力降低,極大增加了患者病死率,導(dǎo)致尿毒癥肌少癥的因素有微炎癥狀態(tài)和運(yùn)動減少等[8]。
MHD患者日常體力活動和身體活動能力下降[9]。MHD患者常見肌肉萎縮和身體功能衰退,生活質(zhì)量顯著下降,可引起心功能異常,進(jìn)一步加劇身體失調(diào),透析患者身體活動能力差可預(yù)測心血管事件、住院和死亡風(fēng)險(xiǎn)[2,10]。本研究亦發(fā)現(xiàn)MHD患者LVEF較對照組下降,并且6MWDs與LVEF呈正相關(guān)。
有氧運(yùn)動是指人體在氧氣充分供應(yīng)的情況下進(jìn)行的體育鍛煉,是耐力鍛煉的一種運(yùn)動形式,即大量肌肉群交替收縮和舒張。Bae等[11]研究發(fā)現(xiàn)12周有氧運(yùn)動可改善血液透析患者身體活動能力,增加6 MWDs,改善生活質(zhì)量。透析期間有氧踏車訓(xùn)練可改善患者體能[2]。本研究顯示,MHD患者經(jīng)6個(gè)月有氧運(yùn)動后,6MWDs、LVEF較之前明顯增加,并且較常規(guī)組亦明顯增加,表明MHD患者可通過有氧運(yùn)動增加身體活動能力,改善心功能,從而保持整體身體機(jī)能,改善生活質(zhì)量。
3.2 有氧運(yùn)動對MHD患者微炎癥狀態(tài)的影響 微炎癥狀態(tài)與CKD患者心血管疾病風(fēng)險(xiǎn)相關(guān),體育鍛煉具有抗炎作用,運(yùn)動改善血液透析患者微炎癥狀態(tài),使炎癥標(biāo)志物高敏CRP顯著降低[3,12]。國外學(xué)者發(fā)現(xiàn)肌肉收縮活動阻斷促炎癥因子信號通路[13]。本研究顯示MHD患者較對照組CRP明顯升高,經(jīng)6個(gè)月有氧運(yùn)動后CRP較治療前明顯降低,同時(shí)較常規(guī)組水平明顯降低,表明MHD患者存在微炎癥狀態(tài),而有氧運(yùn)動可改善MHD患者的微炎癥狀態(tài)。有研究發(fā)現(xiàn)有氧訓(xùn)練可降低空腹血糖和收縮壓,增加血紅蛋白[14-15]。本研究結(jié)果亦顯示MHD患者經(jīng)6個(gè)月有氧運(yùn)動后,空腹血糖、收縮壓較治療前明顯降低,血紅蛋白較治療前明顯增加,并且空腹血糖、收縮壓較常規(guī)組降低,血紅蛋白較常規(guī)組增加,這可能與有氧運(yùn)動改善MHD患者微炎癥狀態(tài)有關(guān)。
3.3 有氧運(yùn)動對MHD患者血網(wǎng)膜素-1的影響 本研究表明MHD患者網(wǎng)膜素-1較對照組升高,與文獻(xiàn)報(bào)道相同[16]。有學(xué)者報(bào)道肥胖女性血網(wǎng)膜素-1 與6MWDs呈顯著正相關(guān),6周耐力訓(xùn)練后血網(wǎng)膜素-1顯著增加[17]。本研究也表明MHD患者6MWDs與血網(wǎng)膜素-1呈正相關(guān),并且MHD患者進(jìn)行6個(gè)月有氧運(yùn)動后,血網(wǎng)膜素-1明顯增加。血網(wǎng)膜素-1可通過以下三方面預(yù)防心血管疾病:(1)與炎癥呈負(fù)相關(guān),具有抗炎作用[18]。(2)改善糖脂代謝[2,14]。(3)血網(wǎng)膜素-1降低可減弱PI-3K/Akt途徑,促進(jìn)鈣化血管的平滑肌向成骨細(xì)胞分化,從而促進(jìn)動脈粥樣硬化[19]。因此,有氧運(yùn)動可以通過增加MHD患者血網(wǎng)膜素-1來預(yù)防心血管疾病。
綜上所述,有氧運(yùn)動可改善MHD患者身體活動能力、心功能、微炎癥狀態(tài)并升高血網(wǎng)膜素-1,進(jìn)一步降低MHD患者心血管事件、住院及死亡風(fēng)險(xiǎn),從而改善MHD患者生存質(zhì)量、延長壽命。
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(2015-10-23收稿 2016-03-01修回)
(本文編輯 李鵬)
Effects of aerobic exercise on 6-minute walk distance and serum level of omentin-1 in hemodialysis patients
LI Ping1,WANG Donghong2△
1 Department of Rehabilitation Medicine,2 Department of Nephrology,The 5thCentral Hospital of Tianjin,Tianjin 300450,China△
Objective To explore the effects of aerobic exercise on 6-minute walk distance and serum level of omentin-1 in maintenance hemodialysis(MHD)patients.Methods A total of 89 MHD patients(MHD group)in the 5thCentral Hospital of Tianjin were included in the study from December 2013 to November 2014.Patients were randomly divided into two groups: routine treatment group(n=43)and aerobic exercise treatment group(aerobic exercise group,n=46).Fifty healthy subjects were selected as normal control group.Both groups received the same hemodialysis and regular treatments,and the aerobic exercise group received 6-month interdialytic aerobic exercise,and the routine group did not take any exercise intervention.The 6-minute walk distances(6MWDs),body mass,height and blood pressure were recorded,and serum levels of omentin-1,C-reactive protein (CRP),blood routine test and biochemistry test were determined in two groups.The relationship between 6 MWDs,age,CRP,left ventricular ejection fraction(LVEF)and omentin-1 were analyzed.Results The serum levels of omentin-1 and CRP weresignificantlyhigher,LVEFwassignificantlylower,inMHDgroupthanthoseofhealthycontrolgroup(P<0.01).After6monthsof aerobicexercise,6MWDs,LVEF,hemoglobinandserumlevelofomentin-1weresignificantlyincreasedthanthosebeforetreatment inaerobicexercisegroup.The6MWDs,LVEFandhemoglobinweresignificantlyincreasedaftertreatmentthanroutine group.The levelsofCRP,fastingglucoseandbloodpressureweresignificantdecreasedaftertreatment.ThelevelsofCRP,fastingglucoseand systolicbloodpressureweredecreasedintreatmentgroupthanthoseofroutinegroup.Beforetreatment,6MWDswasnegativelyrelated with age and CRP,and positively related with LVEF and serum level of omentin-1 in MHD patients(r=-0.418,-0.229,0.252 and 0.234,P<0.05).Conclusion Aerobic exercise can significantly increase values of 6MWDs,LVEF,hemoglobin and serum level of omentin-1,and reduce values of CRP,fasting blood glucose and systolic blood pressure in MHD patients.Aerobic exercise can improve physical performance,heart function and micro inflammatory state,thereby reduce cardiovascular events and mortality risk in MHD patients.
renal dialysis;aerobic exercise;omentin-1;6-minute walk test
R692.5
A
10.11958/20150248
1天津市第五中心醫(yī)院康復(fù)醫(yī)學(xué)科(郵編300450),2腎內(nèi)科
李萍(1963),女,副主任醫(yī)師,大學(xué)本科,主要從事慢性疾病生存質(zhì)量及康復(fù)方面研究
△通訊作者 E-mail:Wangdonghong1x@126.com