维持性血液透析患者的心脏结构改变及预后分析

The abnormalities of cardiac structure and their effects on the prognosis of maintenance hemodialysis patients

目的观察维持性血液透析(MHD)患者心脏结构与功能改变的状况,进行心脏病变危险因素筛查,并进一步探讨其与心脑血管事件的关系。方法横断面及前瞻性随访研究。选取2008年1月至8月北京医院肾内科115例维持性血液透析患者,进行超声心动图(UCG)检查,分析心脏病变的相关因素;随访2年,记录期间发生的心脑血管事件,并分析其相关危险因素。结果横断面研究显示,115例MHD患者中瓣膜钙化92例(80%);左室肥厚80例(69.6%);左房扩大75例(65.2%);左室舒张功能障碍98例(85.6%),左室收缩功能障碍9例(7.83%);肺动脉高压13例(11.3%)。多因素logestic分析示年龄增加、三酰甘油下降与心脏瓣膜钙化相关;收缩压升高是左室肥厚的危险因素;舒张压和尿素清除率(URR)下降与左房扩大独立相关。随访期间有23例(20%)发生心脑血管事件,总死亡18例(15.7%),其中12例(66.7%)死于心脑血管疾病。事件组患者CRP阳性率(43.5%比17.4%,P=0.007)、低白蛋白血症(<35g/L)比例(17.4%比3.3%,P=0.041)、左房内径[(46.7±5.4)比(41.0±6.2)mm,P=0.000]、左室重量指数[(179.5±65.0)比(149.7±50.2)g/m2,P=0.018]高于非事件组。COX多因素分析显示,血浆ALB<35g/L(P=0.004)、CRP阳性(P=0.004)、左房扩大(P=0.014)是发生心脑血管事件的独立危险因素。结论 MHD患者普遍存在心脏结构及功能异常,这也是患者不良心血管预后的危险因素。定期对患者进行UCG检查,有助于早期发现心脏结构和功能的改变,从而有针对性地采取干预措施,改善患者的远期预后。

Objective To investigate the changes of cardiac structure and function,and the correlation of these changes with cardiocerebrovascular events in maintenance hemodialysis（MHD） patients.Methods A total of 115 MHD patients were enrolled in this study,which included cross-sectional study and prospective cohort study.Baseline anthropometric and laboratory parameters were collected,and echocardiography was performed to assess the cardiac structure and function.Cardiocerebrovascular events during the 2-year follow-up period were recorded.Results In the 115 MHD patients,valve calcification was found in 92（80%） patients,left ventricular hypertrophy in 80（69.6%） patients,left atrial enlargement in 75（65.2%） patients,and pulmonary hypertension in 13（11.3%） patients.Cardiac diastolic dysfunction was detected in 98（85.6%） patients,but cardiac systolic dysfunction was only found in 9（7.83%） patients.Multivariate logistic regression analysis revealed that the independent factors for valve calcification were older age and lower serum triglyceride,those for left atrial enlargement were lower diastolic blood pressure and lower urea clearance rate,and the independent factor for left ventricular hypertrophy was higher systolic blood pressure.During the follow-up period,cardiocerebrovascular events occurred in 23（20.0%） patients,and death in 18（15.7%） patients,of whom 12 died of cardiovascular disease.The prevalence of positive C-reactive protein（CRP）,hypoalbuminemia,larger left atrial diameter and heavier LVMI were significantly higher in patients with cardiocerebrovascular events than in those without the events（P0.05）.Cox multivariate regression analyses demonstrated that the independent risk factors for cardiocerebrovascular event included lower serum 465 albumin,positive CRP,and enlargement of left atrium.Conclusions The abnormalities of cardiac structure and function are prevalent in MHD patients,and are also the risk factors for adverse prognosis.Echocardiography should be performed periodically to early detect changes of cardiac structure and function in MHD patients.