血液透析患者肺超声彗星征形成的影响因素及其对预后的影响

Risk factors and impacts on prognosis of ultrasound lung comets in patients undergoing hemodialysis

目的探讨肺超声彗星征在血液透析患者中形成的影响因素及其对预后的影响。方法选取2012年1月至2016年5月莱芜市人民医院维持性血液透析患者142例，男76例，女66例，根据肺彗星指数分级（轻度：0-14，中度：15-30，重度：〉30）分为3组，选取经过心脏超声检查的72名查体健康者作为对照组进行肺部超声检测。对所有患者进行多普勒超声检测肺部及心脏功能，检测分析血常规、生化指标、超敏C反应蛋白、肿瘤坏死因子α。结果基线资料显示，重度组患者年龄大于轻度和中度组，差异均有统计学意义（均P〈0．05）；随着肺彗星指数升高，心功能Ⅲ-Ⅳ级者比例升高（P〈0．05）；左心室射血分数、肺动脉收缩压、透析间期体重增加随肺彗星指数升高而升高，三组间差异均有统计学意义（均P〈0．05）；肿瘤坏死因子α水平随肺彗星指数升高而升高（P〈0．05）。多因素线性回归分析显示，肺彗星分级与心功能分级（P=0．023）、肿瘤坏死因子α（P〈0．001）、超敏C反应蛋白（P=0．042）、透析间期体重增加（P=0．031）、肺动脉收缩压（P〈0．001）呈正相关。Cox回归分析显示肺彗星指数是影响血液透析患者生存的独立危险因素，且肺彗星指数〉30者死亡风险明显升高（HR=3．44，95％CI：1．62-7．26，P=0．001），Kaplan-Meier生存分析显示三组患者全因死亡率差异有统计学意义（χ^2=12．73，P=0．001）。结论血液透析患者肺超声彗星征受多种危险因素作用形成，肺彗星指数是血液透析心脏功能的可靠指标，与血液透析患者的预后独立相关。

Objective To investigate the risk factors of ultrasound lung comets and its impact on the survivals of patients undergoing hemodialysis. Methods One hundred and forty-two patients on hemodialysis （Male 76, female 66） were divided into three groups according to the score of lung comets （mild：≤ 14 comets; moderate： 15 to 30 comets; severe： 〉 30 comets）. Seventy-two healthy subjects examined by lung ultrasound serve as a control. Pulmonary artery systolic pressure and left ventricular ejection fraction （LVEF） were assessed by Doppler uhrasonography. High-sensitivity C-reactive protein （hsCRP） and tumor necrosis factor （TNF）-α were measured by the automatic analyzer and enzyme-linked immunosorbent assay. Results With the increasing age of the patients, lung comets scores increased （P 〈 0. 05 ）. There were significant differences in TNF-α （ P 〈 0. 05 ）, interdialytic weight gain （IDWG） （ P 〈 0. 05 ）, pulmonary artery systolic pressure and LVEF （ P 〈 0. 05 ） among three groups. In multivariate linear regression, the lung comets score was positively related to multiple clinical variables including New York Heart Association （NYHA） classification （ P = 0. 023 ）, hsCRP （ P = 0. 042 ）, TNF-α （ P 〈 0. 001 ）, IDWG （P =0. 031 ）, and pulmonary artery systolic pressure （P 〈 0. 001 ）. In the multivariate Cox proportional hazards models, lung comets score was independent risk factor for death （ P = 0.001 ）. In Kaplan-Meier survival analysis, the risk of all-cause mortality increased in parallel with lung comets score, and patients with lung comets score （ 〉 30 comets） were at highest risk of death among all three groups （log-rank test χ^2= 12.73, P = 0. 001 ）. Conclusion Lung comets is associated with inflammation, pulmonary artery systolic pressure/volume overload and heart function. Lung comets score represents the alterations of heart function and it may serve as a powerful predictor of all-cause mortality for hemodialysis patients.