急性心力衰竭患者并发肾功能恶化影响因素分析及与心力衰竭易损期关系研究

Analysis of Influencing Factors of Worsening Renal Function in Patients with Acute Heart Failure and It′s Relationship with Vulnerable Period of Heart Failure

目的探讨急性心力衰竭(acute heart failure,AHF)患者住院期间发生肾功能恶化(worsening renal function,WRF)的危险因素,构建预测风险的列线图模型,并探讨WRF与心力衰竭易损期的关系。方法选取2020-09/2021-06月因AHF连续入住作者医院心血管内科的成年患者作为研究对象,收集患者的临床资料,以入院5天至出院前估算的肾小球滤过率(estimated glomerular filtration rate,eGFR)较基线资料降低≥20%为WRF的诊断标准,并将患者分为WRF组和非WRF组,随访3个月,记录AHF患者的易损期联合终点事件(全因死亡或因心力衰竭再住院)。分析所有患者并发WRF的危险因素,应用R语言软件(R 4.1.0)构建AHF患者并发WRF风险的列线图模型,并对该模型进行验证,同时探讨WRF与心力衰竭易损期的关系。结果共纳入137例AHF患者,平均年龄(66.50±13.40)岁,男性80例(58%),女性57例(42%)。WRF组63例(45.99%);非WRF组74例(54.01%)。65例患者(47.45%)在易损期发生心血管不良事件,其中,全因死亡24例(17.52%),因心力衰竭再入院41例(29.93%)。多因素Logistic回归分析显示,慢性肾脏病(chronic kidney disease,CKD)、纽约心脏病协会(New York heart association,NYHA)心功能分级高、低钠血症均为AHF患者并发WRF的独立危险因素。预测模型的受试者工作特征(receiver operating characteristic,ROC)曲线的曲线下面积(area under the curve,AUC)为0.825(95%CI:0.757~0.893),预测效能高。单因素Logistic回归分析结果显示,住院期间并发WRF对AHF患者发生易损期联合终点事件的影响无统计学意义(P>0.05)。结论合并CKD、低钠血症、NYHA分级高的AHF患者并发WRF风险升高,本研究构建的列线图模型有助于预测AHF患者并发WRF的风险,住院期间发生WRF不能预测AHF患者发生易损期联合终点事件的风险。

Objective To explore the risk factors of worsening renal function(WRF)in patients with acute heart failure(AHF)during hospitalization,to construct a nomogram model for predicting the risk,and to explore the relationship between WRF and the vulnerable period of heart failure.Methods Adult patients with AHF admitted to the department of cardiovascular medicine in author′s hospital from September 2020 to June 2021 were selected as subjects.The clinical data of the patients were collected.The estimated glomerular filtration rate(eGFR)from 5 days after admission to discharge was more than 20%lower than the baseline data as the diagnostic criteria of WRF.The patients were divided into WRF group and non-WRF group which patients were followed up for 3 months,and the combined end-point events of the vulnerable period of AHF patients(all due to death or re-hospitalization due to heart failure)were recorded.The risk factors of WRF in all patients were analyzed.A nomogram model of AHF patients complicated with WRF was constructed by R language software(R 4.1.0),and the model was verified.At the same time,the relationship between WRF and vulnerable period of heart failure was discussed.Results A total of 137 patients with AHF were included,with the average age of(66.50±13.40),including 80 males(58%)and 57 females(42%).There were 63 cases(45.99%)in WRF group and 74 cases(54.01%)in non-WRF group.65 patients(47.45%)had cardiovascular adverse events during the vulnerable period,of which 24 cases(17.52%)died of all causes and 41 cases(29.93%)were re-hospitalized because of heart failure.Multivariate Logistic regression analysis showed that chronic kidney disease(CKD),high grade of New York heart association(NYHA)and hyponatremia were independent risk factors for WRF in patients with AHF.The area under the curve(AUC)of the receiver operating characteristic(ROC)curve of the prediction model was 0.825(95%CI:0.757-0.893),so the prediction efficiency was high.The results of univariate Logistic regression analysis showed that there was no significant effect of WRF on the occurrence of combined end point events in vulnerable period in patients with AHF(P>0.05).Conclusion Patients with AHF complicated with CKD,hyponatremia and high NYHA grade have an increased risk of WRF.The nomogram model constructed in this study is helpful to predict the risk of AHF patients complicated with WRF.The occurrence of WRF during hospitalization can not predict the risk of combined end-point events in vulnerable period of AHF patients.