目的 研究不同纽约心脏协会心功能分级(NYHA分级)的维持性血液透析(maintenance hemodialysis，MHD)患者的临床特征及其心脏结构功能的变化。 方法 收集佛山复星禅诚医院148例MHD患者，根据NYHA分级将其分为NYHA I级组、 NYHA II级组、NYHA III级组、NYHA IV级组。收集其临床资料、实验室指标及心脏彩超结果，比较不同NYHA分级MHD患者上述指标的变化。 结果 NYHA III级组患者透析间期体质量增长、收缩压与NYHA I级组相比差异有统计学意义(t=2.057,P=0.049；t=2.415, P=0.017)。随着NYHA分级逐渐增高，射血分数保留型心力衰竭(heart failure with preserve ejection fraction，HFpEF)患者占比逐渐减少，射血分数降低型心力衰竭(heart failure with reduced ejection fraction，HFrEF)患者占比逐渐增加(χ2=8.517，P=0.046)；氨基末端脑钠肽(NT-proBNP)、C-反应蛋白(CRP)逐渐增高，白蛋白(ALB)、血红蛋白(Hb)逐渐下降，以NYHA IV级组明显，4组间差异有统计学意义(χ2=9.465，P=0.009；F=6.745，P=0.048；F=6.235，P=0.037；F=6.812，P=0.042)。随着NYHA分级的增加，左心房内径(left atrial diameter，LA)、左心室舒张末期直径(left ventricular end-diastolic diameter，LVEDd)、二尖瓣舒张晚期峰值流速(the late diastolic peak flow velocity，VA)逐渐增加，以NYHA IV级组明显，组间比较差异有统计学意义(F=6.701，P=0.032；F=6.278，P=0.037；F=6.485， P=0.042)；随着NYHA分级增高，左心室射血分数(left ventricular ejection fraction，LVEF)降低，组间比较差异有显著性(χ2=58.216，P＜0.001)。 结论 NYHA III、IV级的MHD患者多合并透析间期体质量增长多、血压控制欠佳。随着NYHA分级增加，微炎症状态、营养不良、贫血逐渐加重，心脏房室内径增大，以舒张功能减退为主，早期识别其舒张功能减退不能局限于二尖瓣舒张早期与舒张晚期峰值流速之比值，需结合二尖瓣舒张早期峰值流速(early diastolic peak velocity，VE)、VA及其动态变化综合判断。
Objective To analyze the clinical characteristics and changes of cardiac structure and function in maintenance hemodialysis (MHD) patients with different New York Heart Association cardiac function grade (NYHA grade). Methods A total of 148 MHD patients were divided into NYHA I group, NYHA II group, NYHA III group and NYHA IV group according to the NYHA classification of their heart function. Clinical data, laboratory indicators and Echocardiography results were collected. Changes of the above indicators were compared in the MHD patients with different NYHA grades. Results There were significant differences in weight gain in the hemodialysis period (t=2.057, P=0.049) and systolic blood pressure (t=2.415, P=0.017) between NYHA III group and NYHA I group. With the increase of NYHA grade, the proportion of heart failure with preserve ejection fraction (HFpEF) patients reduced gradually, and the proportion of patients with heart failure and reduced ejection fraction (HFrEF) increased gradually (χ2=8.517, P=0.046); NT-proBNP and CRP increased gradually, and ALB and Hb decreased gradually, especially in NYHA IV group, with statistical significances among the four groups (χ2=9.465, P=0.009; F=6.745, P=0.048; F=6.235, P=0.037; F=6.812, P=0.042); left atrial diameter (LA), left ventricular end-diastolic diameter (LVEDd) and the late diastolic peak flow velocity (VA) increased gradually, especially in NYHA IV group, and the differences were statistically significant among the groups (F=6.701, P=0.032; F=6.278, P=0.037; F=6.485, P=0.042); left ventricular ejection fraction (LVEF) decreased gradually, with significant differences among the groups (χ2=58.216, ＜0.000). Conclusion MHD patients with NYHA III or IV grade usually show more weight gain and poor blood pressure control during the dialysis period. With the increase of NYHA grade, microinflammatory state, malnutrition and anemia increased gradually, atrial and ventricular diameters increased mainly due to the decrease of diastolic function. Early identification of the decreased diastolic function should combine the values of early diastolic peak velocity (VE) and VA and their dynamic changes rather than limited to the E/A ratio.
[1] 赵德龙.维持性血液透析患者流行病学调查及生存预后相关性分析[D]; 北京：中国人民解放军医学院, 2016：7-8
[2] Collins AJ,Foley RN,Chavers B,et al. US Renal Data System 2013 Annual Data Report [J]. American journal of kidney diseases: the official journal of the National Kidney Foundation, 2014, 63(1 Suppl): A7.
[3] Eknoyan G,Beck GJ,Cheung AK,et al. Effect of dialysis dose and membrane flux in maintenance hemodialysis [J]. The New England journal of medicine, 2002, 347(25): 2010-9.
[4] Trespalacios FC,Taylor AJ,Agodoa LY,et al. Heart failure as a cause for hospitalization in chronic dialysis patients[J]. Am J Kidney Dis,2003, 41(6):1267- 1277.
[5]文锐,代思源,覃娇,等. 维持性血液透析患者不同射血分数心力衰竭的危险因素分析[J].中国血液净化,2018, 17(09): 598-603.
[6] BONAKDAR F,NOORSHARGH P,HEDAYATI P,et al. Investigation of factors related to N-terminal pro-B type natriuretic peptide levels in hemodialysis patients; a single center study[J]. Journal of Nephropharmacology, 2019, 9(1):e5.
[7] 于兆军,姜斌.不同透析方式对NT-ProBNP血浆浓度的影响[J]. 广东医学,2019,40(20):2954-2957
[8] ZELENAK C,CHAVANON M L,TAHIROVIC E,et al.Early NT-proBNP and MR-proANP associated with QoL 1 year after acutely decompensated heart failure: secondary analysis from the MOLITOR trial[J].Biomark Med，2019，13（17）：1493-1507
[9] Scholz SS,Vukadinovi? D,Lauder L,et al. Effects of arteriovenous fistula on blood pressure in patients with end-stage renal disease: a systematic meta-analysis[J]. J Am Heart Assoc, 2019, 8(4):e011183.
[10] Rao NN,Stokes MB,Rajwani A,et al. Effects of arteriovenous fistula ligation on cardiac structure and function in kidney transplant recipients[J]. Circulation, 2019, 139(25):2809-2818.
[11] Ducros J,Larifla L,Merault H,et al. N-terminal proB-type natriuretic peptide and malnutrition in patients on hemodialysis[J]. Int J Nephrol, 2020, 2020: 9528014.
[12] 袁长裕,林峰,郑芬,等. 血液透析滤过对维持性透析患者微炎症状态和营养状态的影响观察与护理[J].中医临床研究,2015,7（33）：58-60。
[13] 陈艳春. 维持性血液透析C-反应蛋白与心血管事件的关联性探究[J].航空航天医学杂志,2018,29（6）：692- 693.
[14] 赖冬梅, 王燕涛.长期血液透析对慢性肾衰竭患者肾性贫血,营养状态及炎症因子水平的影响[J].标记免疫分析与临床, 2019, 26(7):1150-1154.
[15] 杨荆, 肖桦, 樊文星. 老年血透患者营养状况[J].中国老年学, 2019, 39(1):116-118.
[16] 商惠萍,宋晓萍,李学玲等。维持性血液透析患者左心室肥厚相关因素分析[J].中国血液净化, 2017, 16（5）：322-325
[17] Burt JR,Zimmerman SL,Kamel IR, et al. Myocardial T1 mapping: techniques and potential applications[J]. Radiographics, 2014, 34(2): 377-395.
[18] Kai H. Blood pressure variability- induced aggravation of hypertensive organ damages[J]. Nihon Rinsho, 2015, 73(11): 1939-1945.
