【作者】 崔镇花；

【导师】 安昌善；

【作者基本信息】 延边大学 ， 内科学， 2014， 博士

【摘要】 背景及目的：目前随着生物-心理-社会医学模式的建立,人们对心理疾病关注度不断增高。2002年世界卫生组织报告中提到,依目前速度发展,预计2020年抑郁症将成为仅次于冠心病成为世界第二大疾病负担源。抑郁症、焦虑症在维持性血液透析(maintenance hemodialysis,MHD)患者中是最常见的心理疾病,对患者的身心影响巨大,对于MHD患者来说,在某种意义上甚至可以说超过了很多生理和透析指标对患者的影响。近年“抑郁障碍的神经营养假说”,认为抑郁发生是中枢神经系统内以脑源性神经营养因子(brain derived neurotrophic factor, BDNF)产生减少和相关神经可塑性减退所致。提出脑源性神经营养因子有维持神经元生存、促进突触生长的作用,各种原因致脑内BDNF缺少以及大脑功能紊乱可以导致抑郁。BDNF和神经营养素-3(neurotrophin-3,NT-3)是神经营养因子家族中重要成员,对中枢和周围神经系统有广泛作用,在神经精神研究领域受到关注。本研究旨在评估MHD患者的心理健康状况,分析焦虑、抑郁评分与常见生化指标及BDNF和NT-3的关系,筛选影响情绪的指标,以期为焦虑症、抑郁症等心理疾病的发生发展起到预警性作用,及时发现影响心理的相关指标,为早期的发现及预防疾病提供一定依据。也希望通过本研究提高临床医生及患者对心理疾病的认识及重视,在治疗躯体症状的同时给予精神治疗及心理干预,促进身心健康。方法：选取2012年10月～2013年6月期间,在吉林省延边大学附属医院肾病科血透中心行血液透析治疗的资料完整的慢性肾衰患者114名。入组标准：接受维持性血液透析治疗3个月以上终末期肾衰竭患者,前3个月内无透析方式的改变：意识清晰,具有一定交流能力,能理解并配合接受调查；除外神志不清、脑外伤、脑肿瘤及具有人格障碍者；取得受试患者及其家属的同意。正常对照组,系医院职工和志愿者,身体健康,既往无精神病史及类似家族史。血液透析组和正常对照组间年龄与性别无统计学的差异。2组患者均接受一般情况问卷及Zung抑郁自评量表(SDS) Zung焦虑自评量表(SAS)调查,并测定相关化验指标,采用酶联免疫吸附试验(ELISA)检测BDNF和NT-3。采用SPSS17.0统计软件进行分析,计量资料用x±SD表示,计数资料使用百分率(%).。均数之间比较采用独立样本f检验和单因素方差分析,构成比的比较采用x2检验,相关分析采用偏相关分析。趋势检验采用线性回归分析和协方差分析。P<0.05被认为差异有统计学意义。结果：1.长期血液透析的患者抑郁发生率为64%,焦虑发生率为33.3%,抑郁、焦虑症状同时存在的占25.4%,其中轻度抑郁28.1%、中度抑郁25.4%、重度抑郁10.5%,轻度焦虑22.8%、中度焦虑7.9%、重度焦虑2.6%。2.MHD组的血红蛋白、白蛋白、总蛋白、钙、磷、胆固醇水平均低于正常对照组,MHD抑郁组的血红蛋白、白蛋白和钙水平低于MHD非抑郁组,差异有统计学意义。MHD抑郁组NT3水平高于正常对照组和MHD非抑郁组,MHD抑郁组BDNF水平低于正常对照组,差异有统计学意义。3.MHD焦虑组非焦虑组血红蛋白、白蛋白、总蛋白、钙、磷、胆固醇水平均低于正常对照组,C反应蛋白水平高于正常对照组,差异有统计学意义。MHD焦虑和非焦虑NT3水平高于正常对照组,MHD焦虑组的NT3水平高于非焦虑组,差异有统计学意义。4.抑郁和焦虑为应变量,年龄、透析时间、婚姻、收入、血红蛋白、白蛋白、肌酐、尿素氮、C反应蛋白、促甲状旁腺激素、BDNF、NT3为自变量,Logistic回归分析结果影响抑郁的因素有血红蛋白(OR=0.948,95%CIO.908-0.990)、 BDNF(OR=0.907,95%CI:0.847-0.972)、NT3(OR=26.243,95&CI:5.445-126.486)。影响焦虑的因素有尿素氮(OR=1.070,95%CI:1.016-1.126),CRP(OR=1.071,95CI:1.008.1.137),NT-3(OR=1.109,95％CI:1.001-1.228)。结论：1.长期血液透析的患者抑郁、焦虑发病率明显高于正常人群。2.长期血液透析抑郁、焦虑患者营养状况总体较正常人群差。3.长期血液透析患者抑郁影响因素为血色素和BDNF及NT-3,BDNF及NT-3是辅助诊断抑郁障碍的有意义的生物学参考指标；NT-3可能是辅助诊断焦虑的有意义的生物学参考指标。4.应积极治疗终末期肾功能不全并发症,改善患者营养状况有助于减少抑郁、焦虑的发生。5.在患者接受血液透析治疗过程中,医务人员不应仅考虑患者的生存,更应积极评估诊断患者的心理状态,及时给予相应的干预措施,以提高长期血液透析患者生存质量。更多还原

【Abstract】 Background and purpose:The attention to psychological disease is increasing now with the establishment of the biological-psychology-social medical model. In2002the world health organization reported, according to the current development speed, the depression is expected to become the world’s second largest source of disease burden the second only to coronary heart disease in2020.Depression, anxiety is the most common mental illness in maintenance hemodialysis (MHD) patients, the patient’s body and mind has had a huge impact, in some sense, even more than physiological and dialysis parameters. In recent years, neurotrophic hypothesis of depression disorder has been put forward as to the brain derived neurotrophic factor (BDNF) maintain the neurons survival, promote synaptic growth, all sorts of reasons cause a lack of BDNF in the brain and the brain dysfunction can lead to depression. BDNF and neurotrophin-3have wide role in central and peripheral nervous system and received wide attention in the field of neuropsychological research as the important member in the family of neurotrophic factors.The purpose of this study was to assess the mental health status of MHD patients, analysised of anxiety and depression scores and common physiological indexes and the relationship between BDNF and the NT-3, screening index of affect mood, so as to the occurrence of anxiety, depression and other mental illness development play a warning role, timely found psychological influence related indicators, provide a certain basis for the early discovery and prevent diseases. Also hope that through this study to improve the recognition of clinical doctors and patients to mental illness and attention, in the treatment of somatic symptoms at the same time give spiritual and psychological intervention, promote the physical and mental health.Methods:From October2012to June2013,114patients with data integritywho received maintenance hemodialysis treatment in the Hemodialysis center from the Affiliated Hospital of Medical College of Yanbian University inYilin were recruited. The standard set:The patients with end-stage renal failure accepted maintenance hemodialysis more than3months.no dialysis change in the way in3months; Clear consciousness, having certain communication skills, understanding and cooperating with the investigation; Obtain the consent of the patients and their families. Exclusion criteria:exclude dottiness, brain trauma, brain tumors and having a personality disorder.Normal group:Hospital staff and volunteers with health and no mental illness and similar family history previous. No statistical differences between hemodialysis group and normal control group in the age and gender.Both the two groups received general situation questionnaire and Zung depression self rating scale (SDS) Zung self rating anxiety scale (SAS), and the determination of the related test indicators, using enzyme-linked immunosorbent assay (ELISA) detection of BDNF and the NT-3. Using SPSS17.0statistical software for analysis, measurement datas using x±D, count datas using percentage, using independent sample t-test and single factor variance analysis between mean comparison, using x2test in the comparison of structure, using the partial correlation analysisin in correlation analysis, using linear regression analysis and covariance analysis in trend test, P<0.05was considered a significant difference.共病Result:1. The incidence of depression was64%, anxiety was33.3%, the comorbidity was25.4%,28.1%of mild depression, moderate depression, severe depression,25.4%and10.5%,22.8%mild anxiety,7.9%of moderate anxiety,2.6%of severe anxiety in hemodialysis patients.2. The hemoglobin, albumin, total protein, calcium, phosphorus, cholesterol levels in MHD group were lower than that of normal control group, of hemoglobin, albumin and calcium levels in MHD depression groupwere below the non-MHD depression group, the difference was statistically significant.The NT3levels of MHD depression groupwas higher than normal control group and non-MHD group, BDNF level of MHD depression group is lower than the normal control group, the difference was statistically significant.3. The hemoglobin, albumin, total protein, calcium, phosphorus, cholesterol levels in MHD anxietyand non-anxiety group were lower than that of normal control group, c-reactive protein levels higher than the normal control group, the difference was statistically significant.4.The influencing factors of depression were hemoglobin (OR=0.948,95%CI0.908-0.990), BDNF(OR=0.907,95%CI:0.847-0.972)、NT3(OR=26.243,95%CI:5.445-126.486),when Logistic regression analysis was used, depression and anxiety as dependent variable, age, dialysis duration, marriage, income, hemoglobin, albumin, urea nitrogen, creatinine, c-reactive protein, promote the parathyroid hormone, BDNF, NT3as independent variables.Conclusion:1. The incidences of MHD patients with depression, anxiety were significantly higher than normal people.2. The general nutritional status was poor in the MHD patients with depression, anxiety.3. Depression influence factors in in the MHD patients were hemoglobin and BDNF and the NT-3, BDNF and the NT-3meaningful for diagnosis of depression disorders; The influencing factors of anxiety were NT-3, BUN, CRP, the NT-3may be a significant help in the biological diagnosis of anxiety.4. We should reduce the occurrence of depression and anxiety by improving patients nutrition and actively treating end-stage renal failure complications.5. When patients receiving hemodialysis treatment, the medical personnel should not only consider the patient’s survival, but also actively assess and diagnose the patient’s mental state, giving corresponding intervention in time to improve MHD patients life quality.更多还原