肾功能恶化程度和血浆B型利钠肽下降对急性心力衰竭患者预后的影响

Worsening renal function and the plasma B-type natriuretic peptide in prognosis of patients with acute heart failure

目的探讨血浆B型利钠肽(B-type natriuretic peptide,BNP)下降和肾功能恶化(worsening renal function,WRF)程度对急性心力衰竭(acute heart failure,AHF)患者出院后1年全因死亡的影响。方法回顾性分析上海交通大学附属第一人民医院2015年1月至2019年12月收治的399例AHF患者的临床资料,根据WRF轻重程度分为非严重的WRF(non-severe worsening renal function,nsWRF)组、严重的WRF(severe worsening renal function,sWRF)组和无WRF(no worsening renal function,nWRF)组。根据住院期间血浆BNP是否下降分为BNP下降组和BNP未下降组。BNP下降定义为出院或最后1次检测的血浆BNP与入院时相比降低≥30%。收集患者的人口学特征和病史,入院时、住院期间和出院时的临床资料,以及出院后1年的生存状况,比较3组不同WRF程度AHF患者1年病死率和3组不同BNP状态、不同WRF程度AHF患者1年病死率,分析住院期间BNP下降和不同程度WRF对AHF患者1年全因死亡的影响。呈正态分布的计量资料以x¯±s表示,多组间比较采用单因素方差分析,两两比较采用LSD-t检验;非正态分布的计量资料多组间比较采用Kruskal-Wallis秩和检验,两两比较采用Wilcoxon秩和检验。计数资料组间比较采用χ^(2)检验。生存分析采用Kaplan-Meier法和log-rank检验,患者1年全因死亡影响因素分析采用Cox比例风险回归模型。结果399例AHF患者分为nsWRF组68例、sWRF组82例、nWRF组249例,在出院后的1年内死亡86例(21.5%)。sWRF组的1年病死率高于nWRF组和nsWRF组[42.7%(35/82)比16.1%(40/249)、16.2%(11/68)],差异均有统计学意义(χ^(2)值分别为24.94和12.28,均P<0.001),而nWRF组与nsWRF组比较差异无统计学意义(χ^(2)=0.00、P=0.982)。住院期间BNP下降的nWRF组和sWRF组1年病死率均低于BNP未下降组[29.1%(6/55)比70.4%(19/27),10.5%(17/162)比26.4%(23/87),χ^(2)值分别为12.61、10.67,P值分别为<0.001、0.001]。住院期间发生nsWRF不增加AHF患者1年全因死亡风险(P=0.754),但发生sWRF增加AHF患者全因死亡风险(比值比=2.33,95%置信区间:1.31~4.13,P=0.004),住院期间BNP下降降低AHF患者1年全因死亡风险(比值比=0.36,95%置信区间:0.23~0.55,P<0.001)。结论nsWRF不会增加AHF患者的1年全因死亡风险,而sWRF会增加1年全因死亡风险,住院期间BNP下降会降低1年全因死亡风险。

Objective To analyze the effects of different plasma B-type natriuretic peptide(BNP)changes on worsening renal function(WRF)on 1-year all-cause mortality in patients with acute heart failure(AHF).Methods The clinical data of 399 patients with AHF admitted to our hospital from January 2015 to December 2019 were retrospectively analyzed.According to the severity of WRF,the patients were divided into non-severe worsening renal function(nsWRF)group,severe worsening renal function(sWRF)group and non-WRF group.Plasma BNP decrease was defined as a reduction of B-type natriuretic peptide(BNP)at the time of discharge by≥30%compared with the time of admission.Demographic characteristics and medical history,clinical data at admission,during hospitalization and at discharge,and survival status 1 year after discharge were collected.The measurement data presented in the form of normal distribution are as follows:single factor analysis of variance is used for comparison between groups,and LSD-t test is used for comparison between pairs;The Kruskal Wallis rank sum test was used for the multi group comparison of non normal distribution measurement data,and Wilcoxon rank sum test was used for the pairwise comparison.The comparison of counting data between groups was conducted usingχ^(2) test.Survival analysis was conducted using the Kaplan Meier method and Log rank test,and the Cox proportional risk regression model was used to analyze the influencing factors of 1-year all-cause mortality in patients.Results 399 cases of AHF were divided into nsWRF group with 68 cases,sWRF group with 82 cases,and nWRF group with 249 cases.86 cases(21.5%)died within 1 year after discharge.The one-year mortality rate of the sWRF group was higher than that of the nWRF group and nsWRF group[42.7%(35/82)vs 16.1%(40/249),16.2%(11/68)],and the differences were statistically significant(Theχ^(2) values were 24.94 and 12.28 respectively,both P<0.001),while there was no statistically significant difference between the nWRF group and the nsWRF group(χ^(2)=0.00、P=0.982).The 1-year mortality rate of the nWRF group and sWRF group with decreased BNP during hospitalization was lower than that of the non decreased BNP group[29.1%(6/55)vs 70.4%(19/27),10.5%(17/162)vs 26.4%(23/87),Theχ^(2) values are 12.61 and 10.67 respectively,and the P values are<0.001 and 0.001,respectively.The occurrence of nsWRF during hospitalization did not increase the one-year all-cause mortality risk of AHF patients(P=0.754),but the occurrence of sWRF increased the all-cause mortality risk of AHF patients(odds ratio=2.33,95%confidence interval:1.31-4.13,P=0.004).The decrease in BNP during hospitalization reduced the one-year all-cause mortality risk of AHF patients(odds ratio=0.36,95%confidence interval:0.23-0.55,P<0.001).Conclusions NsWRF does not increase the one-year all-cause mortality risk of AHF patients,while sWRF increases the one-year all-cause mortality risk,and a decrease in BNP during hospitalization reduces the one-year all-cause mortality risk.