不同肾小球滤过率冠心病患者的临床特点及其预后

Relationship between estimated glomerular filtration rate level and clinical characteristics and outcome in patients with angiographic coronary artery disease and normal serum creatinine

目的研究血肌酐正常范围内的冠心病患者基线肾功能与其临床特点及其预后的关系。方法纳入经冠状动脉造影明确诊断为冠心病而且血清肌酐正常范围内的住院患者548例。所有患者空腹检测血肌酐，通过肾脏病膳食改良（MDRD）公式估测肾小球滤过率（eGFR），将所有样本按eGFR水平三分位分为3组，其中高eGFR水平组（eGFR〉88．15ml·min^-1·1．73m^-2）184例，中eGFR组（70．30ml·min^-1·1．73m^-2〈eGFR≤88．15ml·min^-1·1．73m^-2）187例，低eGFR组（eGFR≤70．30ml·min^-1·1．73m^-2）177例。记录患者的临床资料及心血管病已知危险因素，并对纳入患者进行随访，平均随访（14．02±8．31）个月，记录终点事件。终点事件定义为不良心脑血管事件（MACCE），包括死亡、靶血管病变重建、非致死性心肌梗死、需要住院治疗的不稳定心绞痛和心功能衰竭、一过性脑缺血或者脑卒中。结果在血清肌酐正常范围内，与高eGFR水平组比较，中及低eGFR水平组患者年龄更高，男性更多，冠状动脉病变严重程度更重，高敏C反应蛋白水平及高血压病的构成比升高，而吸烟构成比下降，差异均有统计学意义（P〈0．05）。随访期间共89例患者发生MACCE，MACCE组患者的eGFR水平明显低于非MACCE组[（73．76±19．81）ml·min^-1·1．73m^-2比（84．97±23．42）ml·min^-1·1．73m^-1，P〈0．05]。单因素及多因素Cox回归分析显示eGFR是冠心病患者发生MACCE的独立预测因素（单因素：RR=0．99，95％CI：0．973^-10．997，P〈0．05；多因素：RR=0．98，95％CI：O．969^-10．998，P〈0．05）。Kaplan．Meier生存曲线显示随着eGFR水平降低，患者的无事件生存率明显降低（log—rank x2=7．271，P〈0．05）。结论血肌酐正常范围内的冠心病患者的eGFR水平与冠状动脉病变严重程度及炎症水平相关，并且可以预测冠心病患者的不良预后。

Objective To explore the relationship between estimated glomerular filtration rate level and clinical characteristics and outcome in coronary artery disease （CAD）patients with normal serum creatinine. Method A total of 548 hospitalized and angiographic CAD patients with normal fasting serum creatinine were enrolled. The kidney function was estimated by using the abbreviated modification of diet in renal disease （MDRD） study equation. Patients were divided into three groups according to eGFR tertiles： high eGFR group （eGFR 〉88. 15 ml·min^-1 · 1.73 m-2 , n = 184） ; intermediate group 组（70. 30 ml·min^-1· 1.73 m 2 〈 eGFR≤88. 15 ml·min^-1 · 1.73 m-2, n = 187） ; low eGFR group （ eGFR≤70. 30 ml·min^-1 ·1.73 m -2, n = 177 ）. Clinical data and cardiovascular risk factors were recorded after admission and during （14. 02 ± 8.31 ） months follow up. The primary end point was combined major adverse cardiovascular and cerebral events （MACCE） including death, targeted vascular revaseularization, non-fatal myocardial infarction, rehospitalization due to unstable angina and heart failure, and transient isehemie attack （TIA） and stroke. Results Patients in intermediate and low eGFR groups were older, more males,had more severe coronary artery disease, higher level of hsCRP, higher incidence of hypertension, and lower smoking rate than those in high eGFR group （ all P 〈 0. 05）. A total of 89 MACCE were recorded during follow up. The level of eGFR was significantly lower in patients with MACCE than patients without MACCE [（73.76_＋19.81） ml ~ min-~ ~ 1.73 m-2 vs. （84.97 ＋23.42） ml ~ min-~ ~ 1.73 m-2, P〈0.05]. Univariate and multivariate Cox regression analysis showed that eGFR was an independent predictor of MACCE in patients with CAD （ univariate analysis： RR = 0. 99, 95% CI： O. 973 - 0. 997, P 〈 0.05 ; multivariate analysis ： RR = 0.98, 95% C1 ： 0. 976 - O. 998, P 〈 O. 05 ）. Kaplan-Meier survival analysis suggested that patients with low eGFR was linked with a decreased event free survival ratio （log-rank X2 =7. 271, P 〈0. 05）. Conclusions eGFR level in CAD patients with normal serum creatinine is associated with coronary artery severity, inflammation level and serves as an independent predictor for MACCE in this patient cohort.