血管外肺水预测慢性肾脏病4~5期患者临床预后的队列研究

Association of extravascular lung water with clinical outcomes in stages 4 and 5 chronic kidney diseases:a prospective cohort study

目的探讨血管外肺水对未接受肾脏替代治疗的慢性肾脏病4~5期患者发生心血管事件、进入肾脏替代治疗及死亡等临床结局的影响。方法选择未接受肾脏替代治疗的慢性肾脏病4~5期237例患者,以肺部超声B线数目评估血管外肺水情况(B线<15为无或轻度肺淤血组,B线≥15为中重度肺淤血组),随访并比较患者临床预后的差异。结果纳入的237例患者中,存在中重度肺淤血者78例(32.9%)。与无或轻度肺淤血组相比,中重度肺淤血组基线合并心血管疾病的比例更高、射血分数更低。所有患者随访14.4(7.4,24.5)个月。在随访期内,84例(35.4%)患者发生心血管事件,115例(48.5%)患者进入肾脏替代治疗,22例(9.3%)患者死亡。多因素Cox回归分析显示,中重度肺淤血组比无或轻度肺淤血组具有更高的心血管事件[HR 2.496(1.598~3.897),P<0.001]、进入肾脏替代治疗[HR 1.739(1.182~2.558),P=0.005]及死亡[HR 3.156(1.325~7.516),P=0.009]风险。结论肺部超声评估的血管外肺水可预测未接受肾脏替代治疗的慢性肾脏病4~5期患者发生心血管事件、进入肾脏替代治疗及死亡等不良结局,有助于该类患者的预后分层。

Objective To evaluate the impact of extravascular lung water volume on cardiovascular events,renal replacement therapy and mortality in pre-dialysis patients with stages 4 and 5 chronic kidney diseases.Methods In this prospective cohort study,237 patients with stages 4 and 5 chronic kidney diseases who had not received renal replacement therapy were enrolled.All patients were divided into the non-or mild-pulmonary congestion group(defined by the number of B-lines<15 in lung ultrasonography)and the moderate or severe pulmonary congestion group(B-lines≥15).During subsequent follow-up,clinical prognosis was compared between two groups.Results Among 237 patients,78(32.9%)were diagnosed with moderate or severe pulmonary congestion.In the moderate or severe pulmonary congestion group,the proportion of patients complicated with cardiovascular diseases was significantly higher(47.4%vs.27.7%,P<0.05)and the ejection fraction was significantly lower((63±9)%vs.(66±6)%,P<0.05)than those in the non-or mild-pulmonary congestion group.During a median follow-up of 14.4(range:7.4,24.5)months,84(35.4%)had cardiovascular events,115(48.5%)initiated renal replacement therapy,and 22(9.3%)died.Multivariate Cox’s regression analysis showed that patients in the moderate or severe pulmonary congestion group had a higher risk of cardiovascular events(adjusted hazard ratio(HR):2.496(1.598-3.897),P<0.001),higher proportion of renal replacement therapy(HR:1.739(1.182-2.558),P=0.005),and higher mortality(HR:3.156(1.325-7.516),P=0.009)compared with those in the non-or mild-pulmonary congestion group.Conclusions These findings suggest that extravascular lung water volume assessed by lung ultrasonography can predict adverse outcomes,such as cardiovascular events,initiating renal replacement therapy and death,in non-dialysis-dependent patients with stages 4 and 5 chronic kidney diseases,which is helpful for stratification of clinical prognosis in this population.