老年慢性肾脏病患者中地高辛致突发性严重心律失常危险因素的分析

Risk factors for digoxin-induced paroxysmal severe arrhythmia in elderly patients with chronic kidney disease

目的 探讨慢性肾脏病老年患者地高辛浓度的影响因素,并分析地高辛所致的突发性严重心律失常的危险因素。方法 回顾性收集2021年1月至12月于广西医科大学第一附属医院心内科重症监护室住院的老年患者115例,根据患者接受地高辛治疗后是否出现严重心律失常分为突发性严重心律失常组(心律失常组)45例和非突发性严重心律失常组(非心律失常组)70例。收集患者临床资料,用多因素回归分析突发性严重心律失常的独立危险因素,采用ROC曲线分析地高辛预测性能。结果 与非心律失常组比较,心律失常组体质量[50.8(47.4,58.5)kg vs 55.0(51.5,65.0)kg]、血红蛋白[(111.4±27.4)g/L vs(123.5±23.2)g/L]、估算肾小球滤过率[38.0(28.7,51.6)ml/(min·1.73 m^(2))vs 49.7(38.6,57.1)ml/(min·1.73 m^(2))]明显降低,尿素[12.2(8.3,16.8)mmol/L vs 8.7(7.7,11.2)mmol/L]、肌酐[0.2(0.1,0.2)mg/L vs 0.1(0.1,0.2)mg/L]、血钾[(4.4±0.6)mmol/L vs(4.2±0.4)mmol/L]、N末端B型钠尿肽前体[5487.0(2497.0,18019.5)ng/L vs 3033.0(1542.0,4800.0)ng/L]、地高辛浓度[1.9(0.9,3.0)μg/L vs 0.7(0.4,1.0)μg/L]及NYHA心功能Ⅲ~Ⅳ级比例(64.4%vs 35.7%)明显升高(P<0.05,P<0.01)。地高辛浓度(95%CI:3.231~17.624,P<0.01)、N末端B型钠尿肽前体(95%CI:1.032~1.167,P<0.05)是发生突发性严重心律失常的危险因素。ROC曲线分析显示,地高辛浓度最佳临界值为1.67μg/L,曲线下面积为0.813(95%CI:0.727~0.898)。结论 过高的地高辛浓度是发生突发性严重心律失常独立危险因素。老年慢性肾脏病患者使用地高辛治疗时应监测地高辛浓度。

Objective To investigate the influencing factors of blood concentration of digoxin in elderly patients with chronic kidney disease(CKD) and to analyze the risk factors of paroxysmal severe arrhythmia caused by digoxin.Methods Clinical data of 115 elderly CKD patients who were hospitalized in ICU of cardiology department of our hospital from January 2021 to December 2021 were collected and retrospectively analyzed.According to the occurrence of severe arrhythmia or not after digoxin treatment, they were divided into paroxysmal severe arrhythmia group(arrhythmia group, n=45) and non-sudden severe arrhythmia group(non-arrhythmia group, n=70).The clinical data of the patients were collected.Multivariate regression analysis was used to analyze the independent risk factors of sudden severe arrhythmia, and ROC curve was drawn to analyze the predictive performance of digoxin.Results The arrhythmia group had significantly lower body weight, hemoglobin and eGFR,and higher levels of blood urea, serum creatinine, potassium and NT-proBNP,higher digoxin concentration and larger proportion of NYHA grade when compared with the non-arrhythmia group [50.8(47.4,58.5)kg vs 55.0(51.5,65.0)kg,(111.4±27.4)g/L vs(123.5±23.2)g/L,38.0(28.7,51.6)ml/(min·1.73 m^(2)) vs 49.7(38.6,57.1)ml/(min·1.73 m^(2)),12.2(8.3,16.8)mmol/L vs 8.7(7.7,11.2)mmol/L,0.2(0.1,0.2)mg/L vs 0.1(0.1,0.2)mg/L,(4.4±0.6)mmol/L vs(4.2±0.4)mmol/L,5487.0(2497.0,18019.5)ng/L vs 3033.0(1542.0,4800.0)ng/L,1.9(0.9,3.0)μg/L vs 0.7(0.4,1.0)μg/L,64.4% vs 35.7%,P<0.05,P<0.01].Digoxin concentration(95%CI:3.231-17.624,P<0.01) and NT-probNP level(95%CI:1.032-1.167,P<0.05) were risk factors for sudden severe arrhythmia.ROC curve analysis showed that the optimal threshold of digoxin concentration was 1.67 μg/L,and the AUC was 0.813(95%:0.727-0.898).Conclusion Higher digoxin concentration is an independent risk factor for paroxysmal severe arrhythmias. Digoxin concentration should be monitored during its therapy in elderly CKD patients.