维持性血液透析患者超声心动图异常情况及危险因素分析  

Echocardiography abnormalities and related risk factors in patients with maintenance hemodialysis

作　　者：聂宇昕 张沥文 杨强 曹学森 孙敏敏 丁小强 NIE Yu-xing;ZHANG Li-wen;YANG Qiang;CAO Xue-sen;SUN Min-min;DING Xiao-qiang(Department of Nephrology,Zhongshan Hospital,Fudan University,Shanghai Institute of Nephropathy and Dialysis,Shanghai Clinical Medical Center of Renal Diseases,Shanghai Key Laboratory of Kidney Diseases and Blood Purification,Shanghai Hemodialysis Quality Control Center,Shanghai 200032,China)

机构地区：[1]复旦大学附属中山医院肾内科,上海市肾病与透析研究所,上海肾脏疾病临床医学中心,上海市肾脏疾病与血液净化重点实验室,上海市血液透析质量控制中心,上海200032

出　　处：《中国临床医学》2023年第3期404-413,共10页Chinese Journal of Clinical Medicine

基　　金：国家自然科学基金(81800677)。

摘　　要：目的分析维持性血液透析(maintenance hemodialysis,MHD)患者经胸超声心动图异常参数及相关危险因素,探讨其与患者预后的相关性。方法前瞻性纳入2017年6月在复旦大学附属中山医院肾内科诊治的MHD患者,随访至2021年12月,记录随访期间患者超声心动图异常参数、患者转归及死亡原因。计算患者左心室质量、左心室质量指数,并记录左心室肥厚(left ventricular hypertrophy,LVH)情况和相对室壁厚度(relative wall thickness,RWT)。采用二元logistic回归模型分析LVH、RWT异常与临床变量、实验室指标的相关性。采用多因素Cox回归模型分析影响MHD患者预后的危险因素。采用Kaplan-Meier和log-rank检验分析超声心动图参数异常对患者预后的影响。结果共纳入MHD患者453例,房性结构异常比例高于室性结构异常比例(63.79%vs 48.34%),舒张功能异常比例高于收缩功能异常比例(75.72%vs5.96%)。269例(59.38%)患者存在LVH,207例(45.70%)患者存在RWT异常,139例(30.68%)患者同时存在LVH和RWT异常。二元logistic回归分析显示,LVH与性别、肺动脉收缩压、血钙、氨基末端脑钠肽前体(NT-proBNP)及有无主动脉瓣反流相关(P<0.05);RWT异常与心肌肌钙蛋白T(cTnT)升高相关(P=0.029)。5年随访期内,210例(46.36%)患者死亡,其中心血管事件占14.76%。多因素Cox回归分析显示,主动脉瓣钙化、免疫球蛋白M(IgM)降低和cTnT升高是患者死亡的独立相关因素(P<0.05)。Kaplan-Meier和log-rank检验显示,无LVH患者(P=0.020)、RWT正常患者(P=0.006)生存期更长,合并主动脉瓣钙化(P<0.001)、二尖瓣钙化(P<0.001)、中重度主动脉瓣反流(P=0.023)、三尖瓣反流(P<0.001)患者的生存期缩短。结论超声心动图参数异常在MHD患者中常见,舒张功能异常较收缩功能异常更常见;合并LVH、RWT异常、瓣膜钙化或瓣膜反流患者预后更差。Objective To analyze the abnormal parameters of echocardiography and related risk factors in patients with maintenance hemodialysis(MHD),and to explore the correlation between abnormal parameters and patients’prognosis.Methods Patients with MHD in Department of Nephrology,Zhongshan Hospital,Fudan University in June 2017 were prospectively enrolled and followed up to December 2021.The abnormal echocardiography parameters,prognosis and cause of death were recorded.The left ventricular mass(LVM)and left ventricular mass index(LVMI)were calculated,and the patients with left ventricular hypertrophy(LVH)or abnormal relative wall thickness(RWT)were recorded.Binary logistic regression model was used to analyze the correlation between LVH,abnormal RWT and clinical variables,laboratory indicators.Multivariate Cox regression model was used to analyze the risk factors affecting the prognosis of patients with MHD.Kaplan-Meier and logrank test were used to analyze the effects of abnormal echocardiographic parameters on the prognosis.Results A total of 453 patients were included in the study.The proportion of atrial structural abnormalities was higher than that of ventricular structural abnormalities(63.79%vs 48.34%),the proportion of diastolic dysfunction was higher than that of systolic dysfunction(75.72%vs 5.96%).Among the 453 patients,269(59.38%)patients had LVH,207(45.70%)patients had abnormal RWT,and 139(30.68%)patients had both LVH and abnormal RWT.Binary logistic regression analysis showed that LVH was significantly correlated with pulmonary artery systolic pressure,serum calcium,N-terminal pro-brain natriuretic peptide(NT-proBNP),gender,and with or without aortic regurgitation(P<0.05).Abnormal RWT was positively correlated with cardiac troponin T(cTnT,P=0.029).During the 5-year follow-up period,210(46.36%)patients died,with cardiovascular events accounting for 14.76%.Multivariate Cox regression analysis showed that aortic valve calcification,reduced immunoglobulin M(IgM)and elevated cTnT were independent ralated fact

关 键 词：维持性血液透析 心血管疾病 超声心动图 左心室肥厚 相对室壁厚度 

分 类 号：R540.45[医药卫生—心血管疾病]