急性心肌梗死患者肾功能状态及对预后的影响

The Relationsc of renal insufficiency and in-hospital prognosis in patients with acute myocardial infarction

目的探评价急性ST段抬高型心肌梗死(STEMI)患者入院即刻肾功能状态及对院内预后的影响。方法多中心、前瞻性队列研究。入选自2005年12月至2007年1月,在发病后24小时内至北京市19家医院就诊的STEMI患者718例。入院即刻测定血清肌酐,根据改良的简化MDRD公式计算估计的肾小球滤过率(eGFR)。分为肾功能正常组(eGFR≥90ml/(min·1.73m2)、轻度肾功能不全组(60ml/(min·1.73m2≤eGFR<90ml/(min·1.73m2)和中度肾功能不全组(eGFR<60ml/(min·1.73m2),比较三组的临床特点和院内死亡和心血管事件发生情况,采用多元Logistic回归分析影响STEMI患者院内死亡和主要心血管事件的危险因素。结果 718例患者中共有280例(39.0%)已经存在不同程度的肾功能不全(eGFR<90ml/min),其中61例(8.5%)为中度以上肾功能不全(eGFR<60ml/min)。与肾功能正常组相比,轻度肾功能不全组和中度肾功能不全组患者年龄偏大(57±12)岁vs(66±13)岁vs(72±13)岁,P<0.01),女性比例多(16.9%vs39.2%vs48.3%,P<0.01),既往有高血压病(47.7%vs59.8%vs70.5%,P<0.01),心力衰竭(0%vs2.7%vs6.6%,P<0.01),脑卒中或一过性脑缺血(TIA)病史(8.9%vs10.6%vs19.3%,P<0.05),入院时心功能Killip≥II级(34.7%vs37.0%vs65.5%,P<0.01)较多。院内病死率(1.4%vs5.9%vs22.9%,P<0.01)和心血管事件(18.0%vs27.4%vs63.9%,P<0.01)显著增高。多因素Logistic回归分析显示入院即刻肾功能不全是STEMI患者发生院内死亡和心血管事件的独立危险因素(OR值分别为3.870;95%CI:1.767-8.474,P<0.01和1.712;95%CI:1.217-2.408,P<0.01)。结论 STEMI患者中肾功能不全发生率较高,院内死亡及心血管事件的发生率随肾功能恶化而增加,肾功能不全是院内死亡和心血管事件的独立危险因素。

Aim To investigate the association of renal insufficiency and in-hospital prognosis in patients with acute ST-segment elevation myocardial infarction（STEMI）. Methods Between December 2005 and January 2007, We enrolled 718 consecutive patients admitted within 24 hours after the onset of STEMI to 19 hospitals in Beijing. Estimation of glomerular filtration rate （eGFR） was conducted by the modified abbreviated MDRD equation-based on the Chinese CKD patients. With the serum creatinine obtained on admission, the patients were categorized according to eGFR： no renal insufficiency （eGFR≥90 ml/（min · 1.73 m2） , mild renal insufficiency （eGFR 为60 - 90 ml/（min · 1.73 m2） and moderate renal insufficiency （eGFR 〈 60 ml/min. 1.73 m2） . The association between renal insufficiency and in-hospital prognosis was studied .Logistic regres- sion analysis was applied to estimate the independent risk factors for in-hospital mortality and malignant adverse cardiovascular events （MACE）. Results 280 patients （39.0%） showed a reduction in eGFR of less than 9 0 ml/ （min. 1.73 m2） , of whom, 61 patients （ 8.5 % ） reached the level of moderate renal insufficiency （ eGFR 〈 60 ml/ （min＇ 1.73 mz） . The in-hospital mortality（0.8% vs 4.1% vslS.3%,P〈0.01 ） and MACE （18.0% vs 27.4% vs63.9%, P〈0.01 ） were also markedly increased in patients with renal insufficiency. After adjusting for other confounding factors, Renal insufficiency was independent risk factors for in-hospital mortality （OR, 3.870; 95% CI ： 1.767-8.474, P 〈 0.01） and MACE （OR, 1.712; 95%CI ： 1.217-2.408, P 〈 0.01）.Conclusion Renal insufficiency is very common in STEMI patients .The in-hospital fatality rate and MACE in STEMI pa- tients with renal insufficiency were higher than those without renal insufficiency. Renal insufficiency evaluated by eGFR is an important independent predictor of in-hospital mortality and MACE.