不同心力衰竭类型对肾功能不全合并心力衰竭患者肾脏远期预后的影响

Impact of different types of heart failure on long-term renal prognosis in patients with renal insufficiency and heart failure

目的探讨不同心力衰竭类型对肾功能不全合并心力衰竭患者肾脏远期预后的影响。方法该研究为回顾性队列研究。纳入首都医科大学附属北京安贞医院2018年1月1日至2019年6月30日肾功能不全[基线估算肾小球滤过率<60 ml·min^(-1)·(1.73 m^(2))^(-1)]合并心力衰竭随访时间≥2年的住院患者。根据入院时超声心动图检查的基线左心室射血分数(left ventricular ejection fraction,LVEF)将患者分为射血分数减低型心力衰竭(heart failure with reduced ejection fraction,HFrEF)组(LVEF<40%)、射血分数轻度减低型心力衰竭(heart failure with mildly reduced ejection fraction,HFmrEF)组(40%≤LVEF<50%)及射血分数保留型心力衰竭(heart failure with preserved ejection fraction,HFpEF)组(LVEF≥50%)。通过电子病历系统收集入选患者的一般临床资料及终点事件(肾功能恶化或全因死亡复合结局)发生情况。采用Kaplan-Meier生存曲线法分析不同心力衰竭亚组的终点事件发生率。采用Cox回归模型分析患者发生终点事件的危险因素。结果共纳入肾功能不全合并心力衰竭患者228例,年龄(68.14±14.21)岁,男性138例(60.5%)。HFrEF组85例(37.3%),HFmrEF组40例(17.5%),HFpEF组103例(45.2%)。三组间年龄、年龄>65岁比例、性别分布、收缩压、肺动脉压、血钠、血钙、血红蛋白、血胆固醇、低密度脂蛋白胆固醇、血尿酸、肌钙蛋白Ⅰ、超敏C反应蛋白、LVEF、室间隔厚度、左心室舒张末内径、B型利钠肽、估算肾小球滤过率及使用β受体阻滞剂、使用螺内酯、心肌梗死、高血压、心肌病、房颤比例的差异均有统计学意义(均P<0.05)。中位随访36.0(28.0,46.0)个月,73例(32.0%)患者发生终点事件,HFrEF组、HFmrEF组及HFpEF组终点事件发生率分别为32.9%(28/85)、35.0%(14/40)及30.1%(31/103)。Kaplan-Meier生存曲线结果显示,三组终点事件发生率的差异无统计学意义(Log-rankχ^(2)=0.17,P=0.680)。多因素Cox回归分析结果显示,HFpEF是终点事件风险增加的独立影响因素(以HFrEF为参照,HR=2.430,95%CI 1.055~5.596,P=0.037)。结论肾功能不全合并心力衰竭患者肾脏远期预后差。相比HFrEF,HFpEF是肾功能不全合并心力衰竭患者肾脏远期预后不良的独立危险因素。

Objective To investigate the effects of different types of heart failure on long-term renal prognosis in patients with renal insufficiency and heart failure.Methods The patients with renal insufficiency[baseline estimated glomerular filtration rate<60 ml·min-1·(1.73 m^(2))^(-1)]and heart failure followed-up for more than 2 years and hospitalized in Beijing Anzhen Hospital,Capital Medical University from January 1,2018 to June 30,2019 were enrolled in this retrospective cohort study.The patients were divided into three groups based on the baseline left ventricular ejection fraction(LVEF):heart failure with reduced ejection fraction(HFrEF,LVEF<40%)group,heart failure with mildly reduced ejection fraction(HFmrEF,40%≤LVEF<50%)group,and heart failure with preserved ejection fraction(HFpEF,LVEF≥50%)group.Clinical data were collected and endpoint events(adverse renal outcome:the composite outcome of all-cause death or worsening renal function)were recorded through the electronic medical record system.Kaplan-Meier survival curve was used to analyze the incidence of endpoint events of different heart failure subgroups.Cox regression model was performed to analyze the risk factors of endpoint events.Results A total of 228 patients with renal insufficiency complicated with heart failure were included,with age of(68.14±14.21)years old and 138 males(60.5%).There were 85 patients(37.3%)in the HFrEF group,40 patients(17.5%)in the HFmrEF group,and 103 patients(45.2%)in the HFpEF group.There were statistically significant differences in age,proportion of age>65 years old,sex distribution,systolic blood pressure,pulmonary artery pressure,serum sodium,serum calcium,hemoglobin,serum cholesterol,low-density lipoprotein cholesterol,serum uric acid,troponin I,hypersensitive C-reactive protein,LVEF,ventricular septal thickness,left ventricular end-diastolic diameter,B-type natriuretic peptide,estimated glomerular filtration rate,and proportions of using beta blockers,using spirolactone,myocardial infarction,hypertension,cardiomyopathy and atrial fibrillation(all P<0.05).During the median follow-up of 36.0(28.0,46.0)months,73 patients(32.0%)had adverse renal outcomes.The total incidences of adverse renal outcomes were 32.9%(28/85)in the HFrEF group,35.0%(14/40)in the HFmrEF group,and 30.1%(31/103)in the HFpEF group.Kaplan-Meier survival curve showed that there was no significant difference in the incidence of endpoint events among the three groups(log-rank testχ^(2)=0.17,P=0.680).Multivariate Cox regression analysis showed that HFpEF(HFrEF as reference,HR=2.430,95%CI 1.055-5.596,P=0.037)was an independent influencing factor of endpoint events.Conclusions The long-term renal prognosis of patients with renal insufficiency and heart failure is poor.Compared with HFrEF,HFpEF is an independent risk factor of poor long-term renal prognosis in renal insufficiency patients with heart failure.