【摘要】目的探讨维持性血液透析(maintenance hemodialysis,MHD)患者中透析充分性达标患者的心脏疾患特点及相关因素。方法选取中日友好医院血液净化中心接受MHD 治疗超过20 年且透析充分的患者20 例，分析患者心脏疾患的临床资料、生化检测和影像学检查结果，研究心脏疾患特点，采用Spearman 相关分析探讨相关因素。结果20 例患者透析龄为20～34 年，其中约75%的患者左心室收缩功能保持正常范围；约60%的患者存在左心室舒张功能减退(left ventricular systolic dysfunction，LVDD)；约70%的患者存在不同程度的瓣膜退行性改变和反流。约35%的患者存在左心房扩大、左心室肥厚、室壁运动障碍、心包积液等损害；生化检测约50%的患者血清心脏损伤标志物超敏肌钙蛋白T(hscTnT)、超敏肌钙蛋白I(hs-cTnI)、B 型利钠肽(BNP)、N 端利钠肽前体(NT-pro BNP)等升高。Spearman 相关分析显示年龄与患者心室舒张功能障碍呈正相关(β=0.583，P=0.007)，心脏疾患与透析龄、是否使用
低分子肝素、血管紧张素转化酶抑制剂/血管紧张素受体拮抗剂类药物、是否联合血液透析滤过、血液灌流治疗等无明确相关。结论对透析充分性达标的MHD 患者，随着年龄和透析龄增长，尽管多数患者左心室收缩功能保持正常，但仍罹患广泛的器质性损伤和左心室舒张功能减退。
【Abstract】objective To investigate the cardiac dysfunction characteristics and related factors in patients with sufficient hemodialysis. Methods Patients who have been treated with sufficient hemodialysis for more than 20 years in China-Japan Friendship Hospital were selected for this study. The general clinical data, laboratory and imaging results of these patients are collected for analysis. Results In the total of 20 patients, the dialysis vintage ranges from 20 to 34 years. About 75% of these patients' left ventricular systolic function remains within the normal range; about 35% of them have suffered different degrees of left ventricular systolic dysfunction (LVDD); and about 70% of them have suffered valve degenerative changes and regurgitation.
More than 35% of them have also suffered left atrial enlargement, left ventricular hypertrophy, abnormal ventricular wall movement, pericardial effusion and other cardiac damages. Biochemical results showed that the serum cardiac injury markers such as high-sensitivity troponin T(HS cTnT), high-sensitivity troponin I (HS cTnI), B-type natriuretic peptide(BNP)and N-terminal natriuretic peptide precursor (NT Pro BNP) increased significantly in about 50% of the patients. Spearman correlation analysis shows that age is positively related to LVDD(β=0.583，P=0.07), but there is no specific correlation between heart disease and dialysis vintage, the usage of low- molecular weight heparin, ACEI /ARB drugs, whether combined hemodialysis with filtration and hemoperfusion therapy. Conclusions With the increase of age and dialysis vintage, although the left ventricular systolic function could be maintained at a normal level in most patients, they still suffer from extensive cardiac structure damage and decreased left ventricular diastolic function.
【1】 Kimura H, Takeda K, Tsuruya K, et al. Left ventricular mass index is an independent determinant of diastolic dysfunction in patients on chronic hemodialysis: a tissue Doppler imaging study. Nephron Clin Pract (2011) 117:c67–c73. doi: 10.1159/000319649.
【2】 超声心动图评估心脏收缩和舒张功能临床应用指南[J].中华超声影像学杂志,2020,29(06):461-477.
【3】 Zhang L, Zhao MH, Zuo L, Wang Y, Yu F, Zhang H, Wang H; CK-NET Work Group. China Kidney Disease Network (CK-NET) 2016 Annual Data Report. Kidney Int Suppl (2011). 2020 Dec;10(2):e97-e185. doi: 10.1016/j.kisu.2020.09.001.
【4】 王廉一，卞维静，李文歌，李爱莉，卢方平，何雯雯，傅芳婷，张凌.血液透析10年患者心脏功能和结构损害的临床研究[J].生物医学工程与临床,2011,15(06):566-569.
【5】 Zoccali C, Bolignano D, Mallamaci F: Left ventricular hypertrophy in chronic kidney disease. In: Oxford Textbook of Clinical Nephrology, 4th Ed., edited by Turner NN, Lameire N, Goldsmith DJ, Winearls CG, Himmelfarb J, Remuzzi G, et al, Oxford, Oxford University Press, 2015, pp 837–852.
【6】 Arcari L, Hinojar R, Engel J, Freiwald T, Platschek S, Zainal H, Zhou H, Vasquez M, Keller T, Rolf A, Geiger H, Hauser I, Vogl TJ, Zeiher AM, Volpe M, Nagel E, Puntmann VO. Native T1 and T2 provide distinctive signatures in hypertrophic cardiac conditions - Comparison of uremic, hypertensive and hypertrophic cardiomyopathy. Int J Cardiol. 2020 May 1;306:102-108. doi: 10.1016/j.ijcard.2020.03.002.
【7】 McIntyre CW: Effects of hemodialysis on cardiac function. Kidney Int 76: 371–375, 2009
【8】 Alqahtani F, Berzingi CO, Aljohani S, et al. Temporal Trends in the Outcomes of Dialysis Patients Admitted With Acute Ischemic Stroke. J Am Heart Assoc.2018 Jun 15;7(12):e008686. doi: 10.1161/JAHA.118.008686.
【9】 Tamarappoo BK, John BT, Reinier K, Teodorescu C, Uy-Evanado A, Gunson K, Jui J, Chugh SS. Vulnerable myocardial interstitium in patients with isolated left ventricular hypertrophy and sudden cardiac death: a postmortem histological evaluation. J Am Heart Assoc. 2012 Jun;1(3):e001511. doi: 10.1161/JAHA.112.001511.
【10】 Okamoto R, Ali Y, Hashizume R, Suzuki N, Ito M. BNP as a Major Player in the Heart-Kidney Connection. Int J Mol Sci. 2019 Jul 22;20(14):3581. doi: 10.3390/ijms20143581.
【11】 Malik J, Kudlicka J, Valerianova A, Kovarova L, Kmentova T, Lachmanova J. Diastolic dysfunction in asymptomatic hemodialysis patients in the light of the current echocardiographic guidelines. Int J Cardiovasc Imaging. 2019 Feb;35(2):313-317. doi: 10.1007/s10554-019-01564-2.
