慢性肾脏病并发肺动脉高压的影响因素及预后价值

Influencing factors and prognostic value of pulmonary arterial hypertension in chronic kidney disease patients

目的探讨慢性肾脏病(chronic kidney disease,CKD)3-5期非透析患者并发肺动脉高压(pulmonary arterial hypertension,PAH)的影响因素,观察PAH对CKD非透析患者预后的影响。方法选择2014年1月1日到2017年1月1日在临沂市人民医院肾内科住院且随访资料完整的CKD3-5期患者。按照是否患有PAH分为PAH组和无PAH组。随访终点:(1)全因死亡;(2)进展到肾脏替代治疗(renal replacement therapy,RRT)。使用Kaplan-Meier生存曲线比较两组患者总生存率和肾脏存活率的差异。采用Cox比例风险回归模型分析预后的影响因素。结果共纳入283例患者,年龄(46.06±14.18)岁,其中男166例(58.66%),女117例(41.34%)。与无PAH组比较,PAH组患者的年龄、血压、C反应蛋白(C-reactive protein,CRP)水平均高于无PAH组(均P<0.05);血红蛋白(hemoglobin,Hb)、红细胞比容(red blood cell specific volume,HCT)、估算肾小球滤过率(estimate glomerular filtration rate,eGFR)、碳酸氢盐、胆固醇水平均低于无PAH组(均P<0.05)。多因素二元Logistic回归分析显示收缩压(systolic blood pressure,SBP)(OR=1.032,95%CI 1.007-1.056,P=0.007)、HCT(OR=0.812,95%CI 0.739-0.892,P<0.001)、碳酸氢盐(OR=0.856,95%CI 0.781-0.938,P<0.001)是CKD非透析患者PAH发生的影响因素。Kaplan-Meier生存分析显示PAH组的生存率比无PAH组显著降低(χ^(2)=13.184,P<0.001),肾脏存活率显著低于无PAH组(χ^(2)=21.948,P<0.001)。多因素Cox回归模型分析显示PAH组的全因死亡风险是无PAH组患者的2.228倍(HR=2.228,95%CI 1.088-4.564,P=0.029),进展至RRT的风险是无PAH组患者的1.692倍(HR=1.692,95%CI 1.064-2.728,P=0.031)。结论高血压、低HCT、低碳酸氢盐水平是CKD3-5期并发PAH的危险因素;PAH是CKD3-5期非透析患者的全因死亡及进展至RRT的危险因素。

Objective To explore the influencing factors of pulmonary arterial hypertension(PAH)in CKD stage 3-5 non-dialysis patients and observe the prognostic influence of PAH.Methods From January 1,2014 to January 1,2017,a total of 283 patients with CKD stage 3-5 were admitted and followed up.They were divided into two groups of PAH and non-PAH.Follow-up endpoints included all-cause mortality and progression to renal replacement therapy(RRT).Kaplan-Meier survival curve was utilized for comparing the differences in overall and renal survivals in each group.Cox proportional risk regression model was employed for analyzing the risk factors affecting poor prognosis.Results There were 166 males(58.66%)and 117 females(41.34%)with an average age of(46.06±14.18)years.Compared with non-PAH group,age,blood pressure and C-reactive protein(CRP)level were all higher in PAH group(all P<0.05).The levels of hemoglobin(Hb),hematocrit(HCT),estimate glomerular filtration rate(eGFR),bicarbonate and cholesterol were all lower than those in PAH group(all P<0.05).Multivariate binary Logistic regression analysis indicated that systolic blood pressure(SBP)(OR=1.032,95%CI 1.007-1.056,P=0.007),hemocrit(HCT)(OR=0.812,95%CI 0.739-0.892,P<0.001)and bicarbonate(OR=0.856,95%CI 0.781-0.938,P<0.001)were influential factors for PAH in non-dialysis CKD patients.Kaplan-Meier survival analysis revealed that survival rate was significantly lower in PAH group than that in non-PAH group(Log-rank,χ^(2)=13.184,P<0.001).And renal survival rate was also significantly lower than that of non-PAH group(Log-rank,χ^(2)=21.948,P<0.001).Multivariate Cox regression model analysis showed that the risk of all-cause mortality was 2.228 folds higher in PAH group than that in PAH group(HR=2.228,95%CI 1.088-4.564,P=0.029).And the risk of progression to RRT was 1.692 folds higher than that in PAH group(HR=1.692,95%CI 1.064-2.728,P=0.031).Conclusion Hypertension,low HCT and low bicarbonate level are risk factors for PAH development in CKD stage3-5.And PAH is a risk factor for all-cause mortality and progression to RRT in non-dialysis CKD patients.