非透析慢性肾脏病患者左心室结构和功能的改变及其影响因素分析

The changes of left cardiac structure and function in the patients with non-dialysis chronic kidney disease and influencing factors

目的分析非透析慢性肾脏病(non-dialysis chronic kidney disease,ND-CKD)患者左心室结构和功能的改变及其影响因素。方法回顾性收集福建医科大学附属第一医院2013年1月至2014年7月住院的ND-CKD患者的临床资料和心脏彩色多普勒超声检查结果,比较不同慢性肾脏病(chronic kidney disease,CKD)分期患者的左心室结构和功能改变,并分析左心室结构和功能改变与临床及生化指标之间的关系。结果共337例ND-CKD患者纳入分析,其中CKD1期71例,2期37例,3期28例,4期36例,5期165例。随着CKD进展,体质量指数(body mass index,BMI)、血钙逐步下降(P<0.05),血尿素氮(BUN)、血肌酐(SCr)、血磷、全段甲状旁腺素(intact parathyroid hormone,iPTH)、胱抑素C逐步上升(P<0.05);25-羟维生素D逐渐下降(P<0.05),N-端骨钙素、β-胶原特殊序列(β-C-terminal telopeptide of typeⅠcollagen,β-CTX)、总Ⅰ型前胶原氨基末端前肽逐渐上升(P<0.05);左心室舒张末期内径(left ventricular end diastolic dimension,LVDd)、左心室收缩末期内径、左心室质量指数(left ventricular mass index,LVMI)数值逐渐增大(P<0.05),而左室相对室壁厚度(relative wall thickness,RWT)各期CKD之间差异无统计学意义。每搏输出量(stroke volume,SV)随着CKD进展而逐渐增大(P<0.05),而心搏出量、左心室射血分数(left ventricular ejection fraction,LVEF)、短轴缩短率、二尖瓣口舒张早期血流速度/舒张晚期血流速度(transmitral diastolic early peak inflow velocity/transmitral diastolic late peak inflow velocity,E/A)值各期CKD之间均无明显差异(P>0.05);但E/A随着CKD进展而逐渐下降,且在CKD2期以后均值均小于1。左室正常构型占各自CKD1~5期例数的百分比逐渐下降,分别为84.5%、70.3%、64.3%、44.4%、38.2%。多元线性回归分析发现,年龄和血磷是RWT的危险因素,BMI是LVDd的危险因素,血β-CTX是LVMI的危险因素,血胱抑素C是SV的危险因素,iPTH是LVEF的危险因素,年龄、女性、血钙和BUN是E/A的保护因素。结论 ND-CKD患者的左心室结构和功能随着CKD进展而恶化,年龄、肾功能、血磷、血钙、iPTH、BMI、血β-CTX与左心室结构和功能改变相关。

Objective To analyze the changes of left ventricular structure and function in the patients with non-dialysis chronic kidney disease（ND-CKD）and the influencing factors.Methods The ND-CKD patients were enrolled from Jan.2013 to July 2014 in our hospital.All patients were subjected to echocardiography and the indexes were collected.Also the clinical data were collected.The indexes of left ventricular structure and function among different CKD groups were analyzed,and the correlation between the changes of cardiac structure and function were clinical data were also analyzed.Results 337 ND-CKD patients were enrolled,including 71 patients with CKD1 stage,37 patientswith CKD2 stage,28 patients with CKD3 stage,36 patients with CKD stage 4 and 165 patients with CKD stage 5.In pace with the progression of CKD,the data revealed that body mass index（BMI）and serum calcium were gradually declined（P〈0.05）,while blood urea nitrogen（BUN）,serum creatinine（SCr）,serum phosphorus,intact parathyroid hormone（iPTH）and Cystatin C gradually ascended（P〈0.05）.New bone metabolic markers revealed that in pace with the progression of CKD,25-（OH）-VitD gradually declined（P〈0.05）,but N-Osteocalcin（NOC）,β-C-terminal telopeptide of typeⅠcollagen（β-CTX）and N-terminal peptide of typeⅠprocollagen（P1 NP）gradually ascended（P〈0.05）.Echocardiographic indexes revealed that in pace with the progression of CKD,left ventricular end diastolic dimension（LVDd）,left ventricular end systolic dimension（LVDs）,and left ventricular mass index（LVMI）gradually ascended（P〈0.05）in cardiac structure,and SV gradually ascended（P〈0.05）in cardiac function,while relative wall thickness（RWT）,cardiac output（CO）,left ventricular ejection fraction（LV-EF）,fractional shortening（FS）,and transmitral diastolic early peak inflow velocity/transmitral diastolic late peak inflow velocity（E/A）had no statistically significant difference,but E/A gradually declined and was less than1 after CKD2.Left ventricular geometric remodeling revealed that the normal LV geometry group gradually declined from CKD1 to CKD5,with84.5%,70.3%,64.3%,44.4%and38.2%respectively.The abnormal LV geometry groups gradually ascended from CKD1 to CKD5,and there were 32.1% with eccentric hypertrophy,15.2% with concentric hypertrophy,and 14.5% with concentric remodeling.Multiple linear regression revealed that the risk factors of RWT were age and serum phosphorus,the risk factor of LVDd was BMI,the risk factor of LVMI wasβ-CTX,the risk factor of SV was Cystatin C,and the protective factors of E/A were age,gender（female）,Ca and BUN.Conclusions The left ventricular structure and function in the patients with ND-CKD were aggravated in pace with the progression of CKD.Age,renal function,serum phosphorus,serum calcium,iPTH,BMI andβ-CTX were related to the changes of left ventricular structure and function.