联合应用eGFR和Hb浓度对冠状动脉介入治疗CKD合并冠心病患者预后价值的初步评价

Preliminary evaluation of the prognostic value of combining eGFR and Hb in CKD patients with coronary artery disease after percutaneous coronary artery intervention

目的探讨估算的肾小球滤过率(eGFR)和血红蛋白(Hb)联合应用对行冠状动脉介入(PCI)治疗慢性肾脏病(CKD)合并冠心病患者住院期间和出院4年内预后预测的价值。方法将1 005例行PCI治疗的冠心病患者依据eGFR和Hb值分成4组:eGFR<60 mL/min合并贫血组18例、eGFR<60 mL/min无贫血组52例、eGFR≥60 mL/min合并贫血组37例、eGFR≥60 mL/min无贫血组898例。检测所有入选患者的血清肌酐和Hb水平,比较分析4组间性别、年龄、吸烟、体重指数(BMI)、高脂血症、高血压、糖尿病、有无心肌梗死病史、术前PCI等基本情况。对所有患者进行随访,随访时间30 d～4年,中位数为3年,采用COX比例风险模型对患者预后进行生存分析,4组间生存曲线的比较使用Kaplan-Meier法,并用对数秩和检验(Log-rank statistic)进行组间生存率的比较。结果 4组之间性别、BMI、术前PCI差异均无统计学意义(P>0.05);吸烟、高脂血症、糖尿病、以前有无心肌梗死、病变支数、年龄、高血压、左心室射血分数(LVEF)在不同eGFR值组间差异有统计学意义(P<0.05)。4组术后住院天数分布差异有统计学意义(H=18.399,P=0.000)。经多因素COX回归分析校正BMI、吸烟、高血压、高脂血症、糖尿病、有无心肌梗死病史、病变支数、术前PCI等危险因素后,发现病变支数增加与发生心脏事件的相对危险度(RR)为1.333[95%可信区间(CI):1.023～1.738,P=0.033];术前PCI与发生心脏事件的RR为3.142(95%CI:1.974～5.001,P=0.000);术前Hb与发生心脏事件的RR为1.006(95%CI:0.990～1.023,P=0.446)。4组内各自1年、2年、3年、4年的每年生存率不尽相同,eGFR<60 mL/min合并贫血组每年生存率分别为94.4%、88.9%、83.3%、83.3%;eGFR<60 mL/min无贫血组分别为98.1%、94.2%、88.5%、86.5%;eGFR≥60 mL/min合并贫血组分别为97.3%、94.6%、91.9%、91.9%;eGFR≥60 mL/min无贫血组分别为99.7%、97.2%、93.7%、91.6%。4组间生存率差异有统计学意义(H=10.440,P=0.015),eGFR<60 mL/min合并贫血组生存率明显低于其他3组。结论 eGFR联合Hb对于评估高心脏事件发生率的行PCI术CKD合并冠心病患者的预后有一定的价值。

Objective To evaluate the prognostic value of combining estimated glomerular filtration rate （eGFR） and hemoglobin （Hb） in chronic kidney disaese （CKD） patients with coronary artery disease after percutaneous coronary artery intervention （PCI）in hospital and 4 years after hospitalization. Methods According to the eGFR and Hb levels, 1 005 PCI patients with coronary artery disease were classified into 4 groups：IS cases in eGFR 〈 60 mL/min and anemia group,52 cases in eGFR 〈 60 mL/min and normal Hb group, 37 cases in eGFR ≥60 mL/min and anemia group and 898 cases in eGFR ≥ 60 mL/min and normal Hb group. The levels of serum creatinine and Hb of PCI patients were measured,and the basic situations of sex, age,smoking,body mass index（BMI） ,hyperlipaemia,hypertension, diabetes mellitus, the presence or absence of prior myocardial infarction and perioperative PCI were compared among the 4 groups. All patients were followed up from 30 d to 4 years, and the median was 3 years. The survival analysis based on COX proportional hazard models. Kaplan-Meier survival analysis was used for comparing survival curves among the 4 groups. The Log-rank statistic was used for comparing survival rate among the groups. Results Sex, BMI and perioperative PCI had no statistical significance among the 4 groups （ P 〉 0.05 ）. Smoking, hyperlipaemia, diabetes mellitus, the presence or absence of prior myocardial infarction, counts of narrow coronary artery, age, hypertension and left ventricular ejection fraction（LVEF） were detected with statistical significance among the 4 groups（P 〈0.05）. The days after PCI had statistical significance （H = 18. 399, P = O. 000）. Through multivariate COX regression correcting BMI,smoking, hypertension, hyperlipaemia, diabetes mellitus, the presence or absence of prior myocardial infarction, counts of narrow coronary artery and perioperative PCI, the relative risk（RR） of the increasing counts of narrow coronary artery with cardiac events was 1. 333 [ 95% confidence interval （CI） ： 1. 023-1. 738, P = O. 033 ]. The RR of perioperative PCI was 3. 142 （95 % CI： 1. 974-5. 001, P = O. 000）. The RR of Hb was 1. 006 （ 95 % CI： O. 990-1. 023, P = 0.446）. The survival rates in the first, second, third and fourth year were different. The each year survival rates of eGFR 〈60 mL/min and anemia group were 94.4%, 88.9%, 83.3% and 83.3% ,of eGFR 〈60 mL/min and normal Hb group were 98.1% , 94.2% , 88.5% and 86.5% ,of eGFR≥60mL/min and anemia group were 97.3% , 94.6% , 91.9% and 91.9% ,and of eGFR≥60 mL/min and normal Hb group were 99.7% , 97.2% , 93.7% and 91.6%. The survival rates had statistical significance among the 4 groups （ H = 10. 440, P = 0. 015 ）, and the survival rate of group with eGFR 〈 60 mL/min and anemia was significantly lower than those of the other 3 groups. Conclusions It has a value to use combining eGFR and Hb to evaluate the prognosis of CKD patients with coronary artery disease after PCI who have a high morbidity of major adverse cardiac events.