左心室重量指数和主动脉弓钙化评分是维持性血液透析患者预后的独立预测因素

Left ventricular mass index and aortic arch calcification score are independent mortality predictors in maintenance hemodialysis patients

目的分析维持性血液透析(maintenance hemodialysis,MHD)患者发生全因死亡、心血管(cardiovascular,CV)死亡和非致死性心血管事件(CV events,CVE)的预测因素,比较血液透析(hemodialysis,HD)和在线血液透析滤过(hemodiafiltration,HDF)对相关因素以及长期预后的影响。方法入组333名MHD患者,随访50±15月,观察全因死亡,CV死亡和CVE发生。在入组基线时,记录人口学资料,测量临床指标。根据入组后的治疗模式,将患者分为HD组(n=268)和HDF组(n=65)。在第6个月末,测量临床和实验室指标。使用COX模型分析基线时全因死亡,心血管死亡和CVE的预测因素。分别使用t检验和Kaplan-Meier生存分析比较组间第6个月末相关因素以及长期预后差异。结果年龄(RR=1.041,P<0.001)、女性(RR=0.615,P=0.020)、左心室重量指数(left ventricula rmass index,LVMI)(RR=1.011,P=0.006)、主动脉弓钙化评分(aortic arch calcification score,AoACS)(RR=1.277,P<0.001),血红蛋白(hemoglobin,Hb)<100g/L(RR=2.609,P<0.001),铁蛋白>500ng/ml(RR=1.637,P=0.037)是发生全因死亡的独立预测因素。C反应蛋白(C-reactive protein,CRP)(RR=1.093,P<0.001)、LVMI(RR=1.030,P<0.001)、AoACS(RR=1.652,P<0.001)和Hb<100g/L(RR=2.144,P=0.016)是发生CV死亡的预测因素。心血管疾病(cardiovascular disease,CVD)病史(RR=3.408,P<0.001),LVMI(RR=1.028,P<0.001)和AoACS(RR=1.329,P=0.003)是发生非致死性CVE的预测因素。第6个月末,HDF组患者体质量指数(body mass index,BMI)(t=-2.494,P=0.013)、体质量(t=-2.252,P=0.023)、总胆固醇(t=-1.992,P=0.047)和Hb(t=-2.175,P=0.030)水平较高,CRP(t=6.432,P<0.001)、LVMI(t=2.420,P=0.017)和AoACS(t=2.337,P=0.020)水平较低。HDF组患者全因死亡(x2=9.610,P=0.002)、CV死亡(x2=4.533,P=0.033)和CVE(x2=4.598,P=0.032)等长期预后更好。结论年龄、性别、LVMI、AoACS、Hb和铁蛋白是MHD患者全因死亡的独立预测因素,CRP、LVMI、AoACS和Hb是CV死亡的独立预测因素。CVD病史、AoACS和LVMI是非致死性CVE的预测因素。HDF能改善MHD患者BMI、体质量、总胆固醇、Hb、CRP、LVMI、AoACS,以及全因死亡、心血管死亡和CVE等长期预后。

Objective To analyze predictive factors for all-cause mortality, cardiovascular （CV） mortality and non-fatal CV events （CVE） in maintenance hemodialysis （MHD） patients, and to compare the effects of standard hemodialysis （HD） and online hemodiafiltration （HDF） on these factors and outcomes. Methods A total of 333 MHD patients were prospectively followed up for 50±15 months, and their all-cause death, CV death and CVE were registered. At the baseline, their demographic, clinical and laboratory data were recorded. Then the patients were stratified according to dialysis modalities into two groups, HD group （n=268） and HDF group （n=65）. At the end of the 6th month, clinical and laboratory data were evaluated again. Thepredictive factors at baseline for all-cause mortality,CV mortality and CVE were analyzed by Cox regression.The effects of HD and HDF on these factors at the6th month and on long-term outcome were compared byt-test and Kaplan-Meier method,respectively.Results Age（RR=1.041,P0.001）,female gender（RR=0.615,P=0.020）,left ventricular mass index（LVMI）（RR=1.011,P=0.006）,aortic arch calcificationscore（AoACS）（RR=1.329,P=0.003）,hemoglobin（Hb）100g/L（RR=2.609,P0.001）,and ferritin500ng/ml（RR=1.637,P=0.037）were the independent predictive factors for all-cause mortality.C-reactiveprotein（CRP）（RR=1.093,P0.001）,LVMI（RR=1.030,P0.001）,aortic arch calcification score（AoACS）（RR=1.652,P0.001）,and Hb100g/L（RR=2.144,P=0.016）were the predictive factors forCV mortality.Prior cardiovascular disease（CVD）（RR=3.408,P0.001）,LVMI（RR=1.028,P0.001）,and AoACS（RR=1.329,P=0.003）were the independent predictive factors for non-fatal CVE.In HDFgroup at the end of the6th month,body mass index（BMI）（t=-2.494,P=0.013）,body weight（t=-2.252,P=0.023）,total serum cholesterol（t=-1.992,P=0.047）,and Hb（t=-2.175,P=0.030）were higher,but CRP（t=6.432,P0.001）,LVMI（t=2.420,P=0.017）,and AoACS（t=2.337,P=0.020）were lower.In HDFgroup,all-cause mortality（？2=9.610,P=0.002）,CV mortality（？2=4.533,P=0.033）,and CVE（？2=4.598,P=0.032）improved with longer survival time and better outcome.Conclusions Age,gender,LVMI,AoACS,Hb,and ferritin were the predictors for all-cause mortality in MHD patients.CRP,LVMI,AoACS,and Hb were associated with CV mortality.Prior CVD,AoACS and LVMI were the independentpredictors for non-fatal CVE.HDF improved BMI,body weight,total serum cholesterol,Hb,CRP,LVMI,AoACS,and long-term outcome including all-cause mortality,CV mortality and non-fatal CVE.