目的 探讨维持性血液透析(maintenance hemodialysis,MHD)患者左心室舒张功能障碍(left ventricular diastolic dysfunction,LVDD)发生的危险因素。 方法 采用回顾性研究，纳入北京市顺义区医院血液净化中心进行维持性血液透析的100例患者,根据多普勒超声心动图结果，记录心尖四腔切面室间隔侧二尖瓣环处舒张早期峰值速度(early diastolic flow-velocity peak,Ve)及舒张晚期峰值速度(late diastolic flow-velocity peak,Va)，计算Ve与Va的比值(Ve/Va)。以Ve/Va＜1作为判断左心室舒张功能障碍的标准，将患者分为LVDD组和无LVDD组；收集2组患者一般资料和生化指标，比较2组间上述各指标的差异性，并采用Logistic回归分析LVDD的危险因素 结果 ①MHD患者 LVDD组糖尿病肾病(diabetic nephropathy,DN)发生率高于左心室舒张功能正常组(χ2=4.332，P=0.024)。②与左心室舒张功能正常组相比，LVDD组收缩压、钙磷乘积、C-反应蛋白(CRP)水平显著增高(t=6.443、5.419、5.107，P=0.033、0.043、0.036)，而血浆白蛋白(Alb)水平显著降低(t=6.759，P=0.008)。③Logistic回归分析显示：收缩压升高可能是MHD患者LVDD发生的独立危险因素(OR=1.245，95% CI:0.987～1.008，P=0.001)，而血浆白蛋白是其保护性因素(OR=2.061，95% CI:0.091～1.239，P=0.037)。 结论 糖尿病肾病、收缩压、营养不良、钙磷乘积升高、CRP升高与MHD患者LVDD发生有关，且收缩压升高、白蛋白降低可能是其重要的独立危险因素。需要引起临床重视。
Objective To explore risk factors of left ventricular diastolic dysfunction (LVDD) in maintenance hemodialysis patients. Methods This study was a retrospective study. One hundred maintenance hemodialysis patients in Blood purification Center of Beijing shunyi district hospital were enrolled. According to the results of doppler echocardiography，the early diastolic flow-velocity peak (Ve) and the diastolic flow-velocity peak (Va) were measured at the mitral annulus on the four-chamber apical view of the heart，and the ratio of Ve to Va was calculated. LVDD was defined as Ve/Va＜1. According to the diagnostic criteria, patients were divided into the LVDD group and the normal group. General information and biochemical index was collected and compared between groups，and logistic regression analysis was used to explore the risk factors of LVDD in maintenance hemodialysis patients. Results ①In the LVDD group，the rate of diabetic nephropathy patients was higher than that in the control group (χ2=4.332，P=0.024). ②There was significant increases in the levels of systolic blood pressure (t=6.443, P=0.033), calcium-phosphorus product (t=5.419, P=0.043) and C-reactive protein (t=5.107, P=0.036) in the LVDD group，and a significant decrease in the level of serum albumin (t=6.759，P=0.008). ③Logistic regression analysis showed that systolic blood pressure was an independent risk factor of LVDD (OR=1.245，95% CI: 0.987～1.008，P=0.001)，and the albumin serves as a protective factor (OR=2.061，95% CI: 0.091～1.239, P=0.037). Conclusions Diabetic nephropathy, systolic blood pressure, malnutrition, calcium-phosphorus product and C-reactive protein are associated with the prevalence of LVDD in maintenance hemodialysis patients. Meanwhile, SBP and serum albumin may be the important independent risk factors of LVDD in maintenance hemodialysis patients.
参考文献
[ 1 ] Zhang W，Mel C，Chen N, et a1.Outcomes and Practice Patterns with hemodiafiltration in Shanghai:A Lon-gitudinal Cohort Study.BMC Nephrology，2019，20，Article No.34.
[ 2 ] Cheung AK, Sarnak MJ, Yan S, et a1.Cardiac disease in maintenance hemodialysis patients: Results of the HEMO study[J].Kidney Int,2004,65(6):2380-2389.
[ 3 ] 侯凡凡．如何改善慢性肾衰竭患者心血管疾病的预后[J]．中华内科杂志，2002，41(8)：507-508．
[ 4 ] Ahmed A, Rich MW, Sanders PW, et a1.Chronic kidney disease associated mortality in diastolic versus systolic heart failure. a propensity matched study[J].Am J Cardiol,2007,99(3):393-398.
[ 5 ] Wang li, Yip GW, Wang AY, et a1.Tissue Doppler imaging provides incremental prognostic value in patients with systemic hypertension and left ventricular hypertrophy [J]. J Hypertens, 2005, 23(1): 183-191.
[ 6 ] Vitarelli A, Conde Y, Cimino E, et a1. Assessment of ascending aorta distensibility after successful coarctation repair by strain doppler echocardiography [J]. J Am Soc Echocardiogr,2008,21(6):729-736.
[ 7 ] Liu M, Takahashi H, Morita Y, et al. Non-dipping is a potent predictor of cardiovascular mortality and is associated with autonomic dysfunction in haemodialysis patients [J]. Nephrol Dial Transplant, 2003, 18: 563-569.
[ 8 ] Barberato SH, Pecoits Filho R. Alteracoes ecocardiograficas em pacientes de hemodialise.Arq Bras Cardiol. 2009. [In press].
[ 9 ] Barberato SH, Ebucharlea SG, Admar M, et a1. Prevalence and Prognostic Impact of Diastolic Dysfunction in Patients with Chronic Kidney Disease on Hemodialysis [J]. Arq Bras Cardiol, 2010, 94(4): 431-436.
[ 10 ] Wang AY,Lam CW,Chan IH,et al.Sudden Cardiac Death in End-Stage Renal Disease Patients:A 5-Year Prospective Analysis[J].Hypertension,2010,56(2):210-216.
[ 11 ] Ayuko Fujiu, Tetsuya Ogawa, Nami Matsuda, et al. Aortic Arch Calcification and Arterial Stiffness are Independent Factors for Diastolic Left Ventricular Dysfunction in Chronic Hemodialysis Patients [J]. Circ J 2008, 72: 1768-1772.
[ 12 ] Kim BS, Jeon DS, Shin MJ, et al. Persistent elevation of C-reactive protein may predict cardiac hypertrophy and dysfunction in patients maintained on hemodialysis [J].Am J Nephrol, 2005, 25(3): 189-195.
[ 13 ] 张英姿,刘宏,高民,刘必成.维持性血液透析患者贫血与左室舒张功能障碍的关系.中国医疗前言,2009,4(17).
[ 14 ] Stojimirovic B, Petrovic D, Obrenovic R, et al. Left ventricular hypertrophy in patients on hemodialysis: importance of anemia. Med Pregl,2007,60 Suppl 2:155-159.
[ 15 ] Qureshi AR,Alvestrand A,Danielsson A,et al.Factors influencing malnutritionin hemodialysis patients. A cross-sectional study[J].Kidney Int.1998,53:773–782.
[ 16 ] Davies SJ, Phillips L, Griffiths AM, et a1.Analysis of the effects of increasing delivered dialysis treatment to malnourished peritoneal dialysis patients. Kidney Int,2000,57(4):1743-1754.
