腹膜透析患者心胸比例的变化及相关因素分析

Changes of cardiothoracic ratio and its risk factors in patients with peritoneal dialysis

目的:探讨腹膜透析(PD)患者心胸比例变化情况及相关影响因素。方法:选取2010年6月至2011年12月于南京军区南京总医院全军肾脏病研究所行PD置管术的123例终末期肾病(ESRD)患者,观察PD治疗后心脏形态相关指标的变化。患者每3月随访一次,全面评估透析状况,包括血清白蛋白、血红蛋白(Hb)、收缩压、舒张压、体重、体质量指数(BMI)、尿量、超滤量、液体清除量、血钠、每周尿素氮总清除率(Kt/Vtotal)、每周肌酐总清除率(Ccr)、残余肾肾小球滤过率(rGFR)水平,并通过心脏超声和胸部平片检查,每6月对PD患者的心脏形态学指标及功能进行评估,观察其动态变化。结果:(1)随PD时间延长患者心胸比例逐渐增加,透析前、透析后6月、12月时分别为0.465±0.041、0.474±0.045、0.492±0.060(P<0.01),射血分数呈下降趋势(P>0.05)。(2)20例(16.3%)患者出现胸闷、夜间不能平卧等心功能不全表现,分析这些患者临床特点发现,糖尿病肾病7例(35%),难治性高血压16例(80%),持续不卧床腹膜透析8例(40%)且rGFR下降快,贫血重。(3)相关回归分析发现,PD患者心胸比例与BMI(r=0.375,β=0.442)、收缩压(r=0.281,β=0.217)、血红蛋白(r=-0.283,β=-0.199)、液体清除量(r=-0.231,β=-0.851)独立相关。(4)不同rGFR状态下心胸比例不同,rGFR水平为<3ml/(min·1.73m2)、3～6ml/(min·1.73m2)、>6ml/(min·1.73m2),心胸比分别为0.493±0.062、0.468±0.043、0.456±0.042(P<0.05)。结论:随着透析时间的延长,PD患者心脏结构及功能发生改变,除与透析本身导致机体容量负荷持续增高外,与残余肾功能、BMI、Hb、液体清除量及血压状态亦密切相关。

Objective： To investigate the change of cardiothoracic ratio and its risk factors in patients with peritoneal dialysis （PD）. Methodology：One hundred and twenty-three patients who received peritoneal dialysis （PD） from June 2010 to December 2011 were enrolled into this prospective study,and the patients with acute kidney injury were excluded. The album, hemoglobin （Hb） blood pressure, body mass index （ BMI）, urine volume, ultrafiltration, fluid removal, residual glomerular filtration rate （ rGFR）, Urea Kt/V, creatinine clearance （Ccr） were examined regularly during the follow up. to explore dynamic changes of all indexes and risk factors of cardiothoracic ratio. To explore dynamic changes of all indexes and risk factors of cardiothoracic ratio, the cardial function and construct were also determined by echocardiography and chest radiograph every 6 month in all patients. Results： （ 1 ） With the extending of time on PD treatment, CTR was gradually increasing. CTR was 0. 465 ± 0. 041,0. 474 ±0. 045,0. 492 ± 0. 060 respectively （P 〈 0. 01 ） on pre-PD, and six, twelve months after PD in all patients. Ejection fraction （EF） presented the downward trend. （2） 20 cases （16. 3% ） showed swollen, chest distress, blood pressure significantly increased and other clinical manifestation of cardia insufficiency. Among them, diabetic nephropathy was in 7 （ 35% ）, refractory hypertension in 16 （ 80% ）, continuous ambulatory peritoneal dialysis in 8 cases （40%）, and these patients were with serious anemia and rapid decline of rGFR. （3） Correlation and regression analysis revealed that BMI （ r = 0. 375 ,/3 = 0. 442 ）, SBP （ r = 0. 281 ,/3 = 0. 217 ） , Hb （ r = - 0. 283 ,/3 = - 0. 199 ） , fluid removal （ r = - 0.231,/3 = - 0. 851 ） were independent factors for CTR. （ 4 ） With