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肺动脉高压(pulmonary artery hypertension,PAH)指静息肺动脉压力(pulmonary artery pressure,PAP)>25 mmHg,或运动时PAP>35 mmHg。PAH分为原发性PAH和继发性PAH,前者是少见疾病,病因不明;后者常继发于心肺基础疾病或肺血管疾病。PAH按照2013年尼斯世界肺动脉高压大会标准可分5型:1型为内在血管疾病引起的PAH;2型与左心功能障碍相关;3型与呼吸系统疾病相关;4型为慢性血栓栓塞性肺PAH;5型为不明原因或多因素所致,包括慢性肾脏病(chronic kidney disease,CKD)或终末期肾病(end-stage renal disease,ESRD)所致[1]。近年研究[2]显示,PAH是CKD及ESRD病人常见并发症之一,且预后极差。检查PAP的方法[3]包括有创和无创检查,前者即右心导管测压,直观准确;后者包括超声心动图、肺功能、CT、核素扫描等,其中,超声心动图是最好的无创检查方法。本研究对ESRD及长期接受血液透析的ESRD病人PAH的发病情况、心脏超声指标及可能的病因进行分析。
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2组血清Scr、BUN、ALB、HB、Ca、P、25(OH)D、iPTH、PAP差异均有统计学意义(P < 0.05~P < 0.01)(见表 1)。观察组PAH发生率为33.3%(22/66),高于对照组的17.7%(11/62)(χ2=4.06,P < 0.05)。
分组 n Scr/(μmol/L) BUN/(mmol/L) ALB/(g/L) HB/(g/L) UA/(mmol/L) Ca/(μmol/L) P/(mmol/L) 25(OH)D/(ng/mL) iPTH/(g/L) PAP/mmHg 观察组 66 837.52±69.23 23.03±3.46 36.11±2.98 96.09±16.16 336.08±60.75 2.39±0.28 2.23±0.28 19.82±8.12 326.89±68.50 34.86±6.80 对照组 62 873.48±64.72 28.97±3.33 33.95±2.87 81.03±13.40 381.10±92.43 2.26±0.29 2.36±0.29 22.87±8.36 359.19±63.30 28.09±6.22 t — 3.03 9.88 4.16 5.72 3.28 2.63 2.52 2.09 2.77 5.87 P — < 0.01 < 0.01 < 0.01 < 0.01 < 0.01 < 0.01 < 0.05 < 0.05 < 0.01 < 0.011 表 1 观察组与对照组肝肾功能、电解质、iPTH、25(OH)D及PAH发生情况比较(x±s)
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PAH组与无PAH组血清Scr、BUN、ALB、HB、Ca、P、25(OH)D差异均无统计学意义(P>0.05),iPTH、血液透析时间差异有统计学意义(P < 0.05和P < 0.01)(见表 2)。
分组 n SCR/(μmol/L) BUN/(mmol/L) ALB/(g/L)L HB/(g/L) P/(mmol/L) Ca/(μmol/L) 25(OH)D/(ng/mL) iPTH/(g/L) 透析时间/月 PAH组 22 848.34±77.52 22.41±3.11 36.41±3.23 93.14±14.01 2.19±0.29 2.38±0.27 19.79±8.12 350.86±38.41 67.84±3.35 无PAH组 44 832.11±64.97 23.34±3.61 35.95±2.88 97.57±17.10 2.25±0.27 2.36±0.25 19.85±8.46 309.91±25.95 68.53±2.68 t — 0.89 1.03 0.58 1.05 0.78 0.29 0.02 2.29 15.98 P — >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 < 0.05 < 0.01 表 2 PAH组与无PAH组肝肾功能、电解质、iPTH、25(OH)D、血液透析时间比较(x±s)
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PAH组与无PAH组的左心房内径、LVEDD、LVMI、LVEF差异均有统计学意义(P < 0.05)(见表 3)。
分组 n LVEDD/mm IVST/mm LVESD/mm LVEF/% E/A 左心房内径/mm 右心房内径/mm 右心室内径/mm LVMI/mm PAH组 22 47.91±3.39 12.50±1.01 34.85±5.59 53.08±4.32 0.89±0.09 36.86±2.34 36.86±2.34 31.86±2.34 202.14±32.39 无PAH组 44 46.09±3.38 12.57±1.04 33.88±5.94 56.85±5.48 0.91±0.13 41.09±1.48 36.11±1.43 31.27±1.42 141.11±53.96 t — 2.05 0.25 0.63 2.82 0.70 4.57 1.63 1.27 4.87 P — < 0.05 >0.05 >0.05 < 0.05 >0.05 < 0.05 >0.05 >0.05 < 0.05 表 3 PAH组与无PAH组病人超声指标比较(x±s)
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非条件logistic回归分析结果显示,LVEDD、左心房内径、LVMI、LVEF、iPTH与PAH的发生有关(P < 0.05)(见表 4)。
变量 B SE Waldχ2 P OR(95%CI) LVEDD 0.297 0.143 4.290 < 0.05 1.346(1.016~1.783) LVEF -0.171 0.084 4.130 < 0.05 0.843(0.715~0.994) 左心房内径 0.996 0.371 7.194 < 0.05 2.708(1.308~5.608) LVMI 0.029 0.009 9.686 < 0.05 1.029(1.011~1.048) iPTH 0.042 0.016 6.891 < 0.05 1.043(1.011~1.076) 表 4 观察组病人并发PAH的多因素logistic回归分析
终末期肾病病人伴发肺动脉高压的临床研究
Clinical study of pulmonary artery hypertension in patients with end-stage renal disease
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摘要:
目的回顾性分析进行血液透析的终末期肾病(ESRD)病人肺动脉压力(PAP)情况,探讨ESRD病人肺动脉高压(PAH)的发生情况及可能的影响因素。 方法选择128例ESRD病人,其中进行血液透析的66例病人作为观察组,无血液透析的62例病人作为对照组,应用超声心动图对病人的PAP进行评估,比较2组病人一般资料、超声心动图结果。并将观察组分为无PAH和PAH组,比较2组实验室检查以及心脏超声指标,分析PAH发病的可能影响因素。 结果观察组与对照组血清肌酐、尿素氮、白蛋白、血红蛋白、血钙、血磷、25(OH) D、全段甲状旁腺激素(iPTH)、PAP差异均有统计学意义(P < 0.05~P < 0.01)。观察组PAH发生率为33.3%,高于对照组的17.7%(P < 0.05)。PAH组与无PAH组血清iPTH、血液透析时间差异有统计学意义(P < 0.05和P < 0.01)。PAH组与无PAH组的左心房内径、左室舒张末期内径、左心室质量指数、左室射血分数差异均有统计学意义(P < 0.05)。Logistic回归分析显示,左室舒张末期内径、左心房内径、左心室质量指数、左室射血分数、iPTH与PAH的发生有关(P < 0.05)。 结论ESRD病人PAH常见,长期血液透析病人发生率更高,左心室结构及功能的改变与PAH密切相关。 Abstract:ObjectiveTo analyze the pulmonary artery pressure(PAP)of 128 end-stage renal disease(ESRD)patients treated with hemodialysis, investigate the occurrence of pulmonary artery hypertension(PAH)in patients with ESRD, and analyze the possible influencing factors of PAH. MethodsAmong 128 ESRD patients, 66 cases treated with hemodialysis and 62 cases without hemodialysis were divided into the observation group and control group, respectively.The PAH in two groups was evaluated by echocardiography, and the general data and echocardiographic results between two groups were compared.The observation group was subdivided into the non-PAH group and PAH group, the laboratory tests and cardiac ultrasound indicators were compared between two groups, and which was used to analyze the possible influencing factors of PAH. ResultsThe differences of the serum levels of creatinine, urea nitrogen, albumin, hemoglobin, blood calcium, blood phosphorus, 25(OH)D, intact parathyroid hormone(iPTH), and PAP between the observation group and control group were statistically significant(P < 0.05 to P < 0.01).The incidence rate of PAH in observation group(33.3%)was higher than that in control group(17.7%)(P < 0.05).The differences of the serum iPTH and hemodialysis time between PAH group and non-PAH group were statistically significant(P < 0.05 and P < 0.01).The differences of left atrial diameter, left ventricular end-diastolic diameter, left ventricular mass index and left ventricular ejection fraction between the PAH group and non-PAH group were statistically significant(P < 0.05).The results of unconditional logistic regression analysis showed that the left ventricular end-diastolic diameter, left atrial diameter, left ventricular mass index, left ventricular ejection fraction and(iPTH)were correlated the with occurrence of PAH(P < 0.05). ConclusionsPAH is common in patients with ESRD, and the incidence rate of which in long-term hemodialysis patients is higher, and the changes of left ventricular structure and function are closely related to PAH. -
Key words:
- end-stage renal disease /
- pulmonary artery hypertension /
- hemodialysis
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表 1 观察组与对照组肝肾功能、电解质、iPTH、25(OH)D及PAH发生情况比较(x±s)
分组 n Scr/(μmol/L) BUN/(mmol/L) ALB/(g/L) HB/(g/L) UA/(mmol/L) Ca/(μmol/L) P/(mmol/L) 25(OH)D/(ng/mL) iPTH/(g/L) PAP/mmHg 观察组 66 837.52±69.23 23.03±3.46 36.11±2.98 96.09±16.16 336.08±60.75 2.39±0.28 2.23±0.28 19.82±8.12 326.89±68.50 34.86±6.80 对照组 62 873.48±64.72 28.97±3.33 33.95±2.87 81.03±13.40 381.10±92.43 2.26±0.29 2.36±0.29 22.87±8.36 359.19±63.30 28.09±6.22 t — 3.03 9.88 4.16 5.72 3.28 2.63 2.52 2.09 2.77 5.87 P — < 0.01 < 0.01 < 0.01 < 0.01 < 0.01 < 0.01 < 0.05 < 0.05 < 0.01 < 0.011 表 2 PAH组与无PAH组肝肾功能、电解质、iPTH、25(OH)D、血液透析时间比较(x±s)
分组 n SCR/(μmol/L) BUN/(mmol/L) ALB/(g/L)L HB/(g/L) P/(mmol/L) Ca/(μmol/L) 25(OH)D/(ng/mL) iPTH/(g/L) 透析时间/月 PAH组 22 848.34±77.52 22.41±3.11 36.41±3.23 93.14±14.01 2.19±0.29 2.38±0.27 19.79±8.12 350.86±38.41 67.84±3.35 无PAH组 44 832.11±64.97 23.34±3.61 35.95±2.88 97.57±17.10 2.25±0.27 2.36±0.25 19.85±8.46 309.91±25.95 68.53±2.68 t — 0.89 1.03 0.58 1.05 0.78 0.29 0.02 2.29 15.98 P — >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 < 0.05 < 0.01 表 3 PAH组与无PAH组病人超声指标比较(x±s)
分组 n LVEDD/mm IVST/mm LVESD/mm LVEF/% E/A 左心房内径/mm 右心房内径/mm 右心室内径/mm LVMI/mm PAH组 22 47.91±3.39 12.50±1.01 34.85±5.59 53.08±4.32 0.89±0.09 36.86±2.34 36.86±2.34 31.86±2.34 202.14±32.39 无PAH组 44 46.09±3.38 12.57±1.04 33.88±5.94 56.85±5.48 0.91±0.13 41.09±1.48 36.11±1.43 31.27±1.42 141.11±53.96 t — 2.05 0.25 0.63 2.82 0.70 4.57 1.63 1.27 4.87 P — < 0.05 >0.05 >0.05 < 0.05 >0.05 < 0.05 >0.05 >0.05 < 0.05 表 4 观察组病人并发PAH的多因素logistic回归分析
变量 B SE Waldχ2 P OR(95%CI) LVEDD 0.297 0.143 4.290 < 0.05 1.346(1.016~1.783) LVEF -0.171 0.084 4.130 < 0.05 0.843(0.715~0.994) 左心房内径 0.996 0.371 7.194 < 0.05 2.708(1.308~5.608) LVMI 0.029 0.009 9.686 < 0.05 1.029(1.011~1.048) iPTH 0.042 0.016 6.891 < 0.05 1.043(1.011~1.076) -
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