维持性血液透析患者合并肺动脉高压的临床及预后分析

Clinical and prognostic analysis of pulmonary hypertension in maintenance hemodialysis patients

目的探讨血液透析(hemodialysis,HD)患者合并肺动脉高压(pulmonary hypertension,PAH)的相关因素及预后,以便早期诊断及干预PAH。方法采用回顾性队列研究的方法,选取2010年1月1日至2015年12月30日中山大学附属第三医院血液净化中心随访资料完整的长期HD患者183例,随访截止时间为2017年12月30日,观察终点为死亡和主要心血管事件。比较有PAH(PAH组)和无PAH组患者的临床资料、实验室检查、心脏彩超相关指标及预后。采用多因素Logistic回归分析HD患者并发PAH的危险因素。生存率计算采用Kaplan-Meier法,生存曲线比较采用Log-rank检验。PAH与全因死亡率的相关性检查采用多因素Cox比例风险回归模型。结果183例HD患者中女性79例(43.2%),男性104例(56.8%),年龄(56.1±16.9)岁,其中合并PAH患者72例(39.3%)。与无PAH组相比,PAH组年龄和透析龄较大(均P<0.05)。两组心脏彩超资料比较,PAH组左心房内径(P=0.002)与瓣膜钙化发生率(P=0.004)显著高于无PAH组。Logistic回归分析提示年龄增加(OR=1.027,95%CI 1.001~1.053,P=0.041)及透析龄增加(OR=1.129,95%CI 1.004~1.269,P=0.042)是HD患者并发PAH的危险因素。在中位随访27.8个月后,Kaplan-Meier生存分析结果显示,PAH组全因死亡率高于无PAH组且差异有统计学意义(χ^2=5.636,P=0.018)。两组患者死亡的主要原因均为心血管事件。Cox回归结果显示,校正年龄、合并糖尿病、透析龄、合并瓣膜钙化、合并高血压等因素后,PAH增加了HD患者的全因死亡风险(HR=1.894,95%CI 1.083~3.313,P=0.025)。结论HD患者合并PAH比较常见且预后不良。年龄增加和透析龄增加可能是HD患者并发PAH的危险因素。定期的心脏彩超检查有助于早期发现并诊断PAH。

Objective To investigate the related factors and prognosis of pulmonary hypertension (PAH) in hemodialysis (HD) patients for early diagnosis and intervention of PAH. Methods A retrospective cohort study was conducted in 183 long-term hemodialysis patients with complete follow-up data from January 1, 2010 to December 30, 2015 from the blood purification center of the Third Affiliated Hospital of Sun Yat-sen University. The follow-up deadline was December 30, 2017, and the endpoints were death and cardiovascular events. The clinical data, laboratory examinations, cardiac color Doppler ultrasound parameters and prognosis of patients with and without PAH were compared. Multivariate logistic regression was used to analyze the risk factors for PAH in HD patients. The survival rates were calculated by Kaplan-Meier method, and the survival curves were compared by Log-rank test between the two groups. A multivariate Cox proportional hazard regression model was used to examine the association between PAH and all-cause mortality in HD patients. Results Of the 183 hemodialysis patients, 79(43.2%) were female, 104(56.8%) were male, and the age was (56.1±16.9) years, of which 72(39.3%) were complicated with PAH. Compared with the non-PAH group, patients in the PAH group was older and had a longer duration of dialysis (both P<0.05). The left atrial diameter (P=0.002) and the proportion of valvular calcification (P=0.004) were significantly higher in the PAH group than that in the non-PAH group. Logistic regression analysis showed increased age (OR=1.027, 95% CI 1.001-1.053, P=0.041) and increased duration of dialysis (OR=1.129, 95% CI 1.004-1.269, P=0.042) were risk factors for PAH in HD patients. After a median follow-up of 27.8 months, Kaplan-Meier survival analysis showed that all-cause mortality was higher in the PAH group than that in the non-PAH group (χ^2=5.636, P=0.018). The main cause of death in two groups was cardiovascular event. After adjusting for age, diabetes mellitus, duration of dialysis, valvular calcification, and hypertension, Cox regression showed that PAH increased the risk of all-cause mortality in HD patients (HR=1.894, 95% CI 1.083-3.313, P=0.025). Conclusions HD patients complicated with PAH are more common and the prognosis is poor. Increased age and increased duration of dialysis may be risk factors for PAH in HD patients. Regular color Doppler echocardiography is helpful for early detection and diagnosis of PAH.