慢性肾病患者高敏心肌肌钙蛋白T动态增高的非AMI病因研究

The etiologic study of dynamic increased high-sensitivity cardiac troponin T in patients with chronic kidney disease

目的探讨不伴急性心梗的慢性肾脏疾病(CKD)患者高敏心肌肌钙蛋白T(hs-cTnT)动态增高的病因。方法纳入2016年1月至2018年1月四川大学华西医院肾脏内科住院因胸痛在12 h内测定两次hs-cTnT且不伴急性心肌梗死的慢性肾病患者,两次hs-cTnT水平增高≥50%为病例组,hs-cTnT水平增高<50%为对照组,收集患者实验室检查结果和临床资料,寻找CKD患者hs-cTnT动态增高的病因。结果病例组高血压51例(70.8%)、低蛋白血症46例(63.9%)、贫血52例(72.2%)、消化道出血23例(31.9%)患者所占比显著高于对照组,差异有统计学意义(P<0.05);12 h内病例组肾功能指标尿素(Urea)、肌酐(Crea)、尿酸(UA)、胱抑素-C(Cys-C)分别从21.0 mmol/L、408.0μmol/L、408.0μmol/L、4.0 mg/L上升至26.0 mmol/L、493.0μmol/L、438.0μmol/L、5.0 mg/L(P<0.05),感染指标白细胞计数(WBC)、降钙素原(PCT)分别从8.0×109/L、1.0 ng/mL上升至10.0×109/L、5.0 ng/mL(P<0.05),呼吸功能指标氧分压(PO 2)从88.0 mm Hg降至77.0 mm Hg(P<0.05),对照组则无此变化;病例组hs-cTnT变化率[85.12(57.17~138.28)]%显著高于对照组[21.31(15.35~41.14)]%,差异有统计学意义(P<0.05),病例组Urea、Crea、UA、Cys-C、WBC、PCT、PO 2变化率显著高于对照组,差异有统计学意义(P<0.05),hs-cTnT水平变化率与Urea、Crea、UA、Cys-C、WBC、PCT变化率呈正相关(r=0.311、0.315、0.216、0.201、0.301、0.229,P=0.026、0.006、0.013、0.031、0.004、0.019),与PO 2变化率呈负相关(r=-0.303,P=0.027)。Crea、PCT、PO 2的改变与hs-cTnT水平动态增高呈独立相关(B=23.130、4.229、-2.650,Beta=0.309、0.065、-2.870,P=0.037、0.019、0.017)。结论肾功能急剧下降、感染加重、缺氧是CKD患者hs-cTnT大幅升高的非急性心肌梗死的病因。

Objective To investigate the causes of dynamic increase of high sensitivity troponin T(hs-cTnT)in chronic kidney disease(CKD)patients without acute myocardial infarction.Methods From January 2016 to January 2018,CKD patients without acute myocardial infarction from the department of nephrology,West China Hospital of Sichuan University,were enrolled.The levels of hs-cTnT and other laboratory indicators were determined twice within 12 hours because of chest pain,the case group was defined as the increase rate as hs-cTnT levels increased 50%or higher from the first time to the second time,while the control group was defined as the increase rate less than 50%.The laboratory test results and clinical information were collected to find the cause of the dynamic increase of hs-cTnT in CKD patients without acute myocardial infarction.Results The proportion of patients with hypertension 51 cases(70.8%),hypoproteinemia 46 cases(63.9%),anemia 52 cases(72.2%)and gastrointestinal bleeding 23 cases(31.9%)in the case group was significantly higher than that in the control group,the difference was statistically significant(P<0.05).The renal function indexes in the case group:Urea,Crea,UA and Cys-C increased from 21.0 mmol/L,408.0μmol/L,408.0μmol/L and 4.0 mg/L to 26.0 mmol/L,493.0μmol/L,438.0μmol/L and 5.0 mg/L,respectively,within 12 h(P<0.05).WBC and PCT increased from 8.0×109/L and 1.0 ng/mL to 10.0×109/L and 5.0 ng/mL,respectively(P<0.05).Respiratory function index:PO 2 decreased from 88.0 mm Hg to 77.0 mm Hg(P<0.05),but no change was observed in the control group.The change rate of hs-cTnT in the case group was[85.12(57.17-138.28)]%within 12 hours,which was significantly higher than that of the control group[21.31(15.35-41.14)]%,the difference was statistically significant(P<0.05).The change rates of Urea,Crea,UA,Cys-C,WBC,PCT and PO 2 in the case group were all higher than those in the control group,the difference was statistically significant(P<0.05).hs-cTnT levels were positively correlated with the rates of Urea,Crea,UA,Cys-C,WBC and PCT(r=0.311,0.315,0.216,0.201,0.301,0.229,P=0.026,0.006,0.013,0.031,0.004,0.019).It was negatively correlated with the change rate of PO 2(r=-0.303,P=0.027).Moreover,the changes of Crea,PCT and PO 2 were independently correlated with the dynamic increase of hs-cTnT level(B=23.130,4.229,-2.650,Beta=0.309,0.065,-2.870,P=0.037,0.019,0.017).Conclusion Acute renal function decline,increased infection,and hypoxia are the causes of non-acute myocardial infarction with significantly elevated hs-cTnT in patients with CKD.