腹膜透析患者左室肥厚的相关因素分析

doi:10.3877/cma.j.issn.2095-3216.2016.06.005

目的

探讨腹膜透析患者左心室肥厚的发生情况及相关影响因素。

方法

选取2012年9月至2013年9月在广西医科大学第一附属医院腹膜透析中心随访的腹膜透析患者89人，规律腹膜透析6个月以上。排除标准：近一个月有腹膜炎或其他部位感染史，合并有急性心衰、慢性阻塞性肺疾病、恶性肿瘤、急性心脑血管病变、风湿性心脏病、严重肝功能不全及近3个月内使用糖皮质激素及免疫抑制剂的患者。采集入选病例临床资料，并予心脏彩超检查，通过测量室间隔厚度(LVST)、左心室厚度(LVPWT)、左室舒张内径(LVEDD)计算左心室心肌重量指数(LVMI)。左室肥厚定义为LVMI男性≥115 g/m²，女性≥95 g/m²。分析患者的横断面资料，并将患者分为左室肥厚组及非左室肥厚组进行比较。采用SPSS 17.0统计软件进行数据分析。两变量相关分析用Pearson(正态资料)或Spearman(非正态资料)相关分析。左室肥厚的独立危险因素分析用二分类Logistic回归分析，P<0.05认为差异有统计学意义。

结果

89例患者中，男女比为1.47∶1，年龄(48.49±12.27)岁，腹膜透析龄(25.35±24.30)个月。病因：慢性肾小球肾炎61例(68.54%)、高血压肾病16例(17.98%)、糖尿病肾病2例(2.25%)、其他病因10例(11.24%)。左心室肥厚66例(74.16%)。将左心室肥厚组与非左心室肥厚组的相关指标进行比较。两组患者的血脑利钠肽前体(NT-proBNP)、腹膜透析液肌酐与血中清肌酐比值(D/P)、血白蛋白、左室射血分数(LVEF)、LVEDD、左室收缩末期内径(LVESD)、左房内径(LAD)、LVPWT及LVST等差异有统计学意义(P<0.05)。左心室肥厚与NT-proBNP、D/P值、LVEDD、LVST、LAD、LVESD及LVPWT呈正相关(P<0.05)，与LVEF呈负相关(r＝－0.222，P＝0.036)。NT-proBNP水平是左室肥厚的独立危险因素(B偏回归系数0.001，SE值：0.000，Wals值：13.45，95%CI为1.000～1.001, P<0.001)。

结论

腹膜透析患者较易发生左心室肥厚，其左心室肥厚与营养状态、容量负荷及腹膜转运类型等相关，NT-proBNP水平有望成为腹膜透析患者左室肥厚的评估预测生物标志物。

关键词: 腹膜透析, 左室肥厚, 影响因素

Objective

To investigate about the development and correlative factors of left ventricular hypertrophy (LVH) in patients with peritoneal dialysis.

Methods

89 patients were enrolled who had received regular peritoneal dialysis for more than 6 months in the First Affiliated Hospital of Guangxi Medical University from September 1st, 2012 to September 1st, 2013. Exclusion criteria included patients who had a history of peritonitis or other infections within 1 month, who were complicated with acute heart failure, chronic obstructive pulmonary disease, cancer, acute cardio-cerebrovascular lesions, rheumatic heart disease, serious liver failure, or who had received treatment with glycocorticosteroids and immunosuppressors within 3 months. The clinical data of selected cases were collected, and echocardiography examination was given, with the left ventricular mass index (LVMI) being calculated through by measuring interventricular septum thickness, left ventricular thickness, and left ventricular diastolic internal diameter. The LVH was defined as LVMI ≥115 g/m² in male, and ≥95 g/m² in female. The SPSS 17.0 statistical software was used for data analysis, and p< 0.05 indicated that the difference was statistically significant.

Results

The 89 patients had a male to female ratio of 1.47∶1, aged 48.49±12.27, and the peritoneal dialysis duration was 25.35±24.30 months. The etiology for peritoneal dialysis included chronic glomerulonephritis in 61 cases (68.54%), hypertensive nephropathy in 16 cases (17.98%), diabetic nephropathy in 2 cases (2.25%), and other causes in 10 cases (11.24%). The prevalence of LVH was 74.16% (66 cases). The differences between LVH group and non-LVH group were statistically significant in N-terminal pro-brain natriuretic peptide (NT-proBNP), ratio of peritoneal dialysis solution creatinine to plasma creatinine (D/P), albumin (Alb), left ventricular ejection fraction (LVEF), left ventricular end diastolic diameter (LVEDD), left ventricular end systolic diameter (LVESD), left atrial diameter (LAD), left ventricular posterior wall thickness (LVPWT), and left ventricular septal thickness (LVST) (P<0.05). The LVH was negatively correlated with LVEF (P<0.05), but was positively correlated with NT-proBNP, D/P value, LVEDD, LVESD, LAD, LVPWT, and LVST (P<0.05). The NT-proBNP was an independent risk factor for LVH (P<0.001).

Conclusion

There was a high prevalence rate of LVH in the patients with peritoneal dialysis, which was closely related with nutritional status, volume load, and peritoneal transport type, etc. The NT-proBNP might be a biomarker for evaluation and prediction of LVH in patients with peritoneal dialysis.

Key words: Peritoneal dialysis, Left ventricular hypertrophy, Affecting factor

表1 左室肥厚组与非左室肥厚组的临床和相关检查资料比较

组别	例数	年龄(岁)	性别(男/女)	透析龄(月)	BMI(kg/m²)	NT-proBNP(ng/L)	D/P－	透析量(ml/d)
左室肥厚组	66	48.4±11.6	39/27	25.6±26.9	22.4±3.6	6 805.9±7489.5	0.7±0.1	7 913.0±733.2
非左室肥厚组	23	48.7±14.3	14/9	24.7±14.9	23.8±4.1	1 658.7±2127.9	0.6±0.1	7 969.7±1022.4
检验值	?	1.190	0.022	3.149	2.710	8.467	0.178	0.171
P值	?	0.912	0.881	0.874	0.116	0.002	0.007	0.808
组别	例数	尿量(ml/d)	超滤量(ml/d)	eGFR[ml/(min·1.73 m²)]	总KT/V－	总Ccr(ml/min)	血红蛋白(g/L)	白蛋白(g/L)
左室肥厚组	66	632.0±528.0	643.2±501.7	1.7±2.3	1.7±0.7	62.8±126.0	87.2±20.0	33.5±4.9
非左室肥厚组	23	765.2±542.0	634.4±501.8	1.6±2.3	1.6±0.4	61.1±26.0	92.4±20.6	35.9±4.2
检验值	?	0.180	0.091	0.570	5.156	0.359	0.069	0.186
P值	?	0.303	0.942	0.814	0.305	0.770	0.285	0.046
组别	例数	甲状旁腺素(ng/L)	血钙(mmol/L)	血磷(mmol/L)	血钾(mmol/L)	血糖(mmol/L)	尿素氮(mmol/L)	收缩压(mmHg)	舒张压(mmHg)
左室肥厚组	66	402.1±295.0	2.2±0.3	1.8±0.7	4.0±0.6	5.0±1.0	19.6±5.6	143.3±17.4	87.1±11.5
非左室肥厚组	23	355.8±405.8	2.2±0.2	1.8±0.6	4.3±0.8	4.9±1.1	19.5±5.4	143.4±17.0	87.6±14.8
检验值	?	0.033	0.299	0.210	0.020	0.730	11.033	0.812	0.460
P值	?	0.559	0.235	0.979	0.131	0.907	0.084	0.997	0.871
组别	例数	TC(mmol/L)	LDL(mmol/L)	心胸比－	LVEF(%)	LVEDD(mm)	LVESD(mm)	LVST(mm)	LVPWT(mm)
左室肥厚组	66	5.2±1.1	3.0±0.9	0.5±0.1	64.0±48.5	62.4±5.4	45.4±7.6	12.5±1.2	11.9±1.4
非左室肥厚组	23	5.9±2.7	3.2±1.2	0.5±0.0	87.0±34.4	48.3±5.3	30.4±4.3	10.3±1.5	9.7±1.4
检验值	?	4.358	3.603	0.343	32.30	0.027	8.995	0.337	0.017
P值	?	0.088	0.431	0.886	0.036	<0.001	<0.001	<0.001	<0.001

表1 左室肥厚组与非左室肥厚组的临床和相关检查资料比较

组别	例数	年龄(岁)	性别(男/女)	透析龄(月)	BMI(kg/m²)	NT-proBNP(ng/L)	D/P－	透析量(ml/d)
左室肥厚组	66	48.4±11.6	39/27	25.6±26.9	22.4±3.6	6 805.9±7489.5	0.7±0.1	7 913.0±733.2
非左室肥厚组	23	48.7±14.3	14/9	24.7±14.9	23.8±4.1	1 658.7±2127.9	0.6±0.1	7 969.7±1022.4
检验值	?	1.190	0.022	3.149	2.710	8.467	0.178	0.171
P值	?	0.912	0.881	0.874	0.116	0.002	0.007	0.808
组别	例数	尿量(ml/d)	超滤量(ml/d)	eGFR[ml/(min·1.73 m²)]	总KT/V－	总Ccr(ml/min)	血红蛋白(g/L)	白蛋白(g/L)
左室肥厚组	66	632.0±528.0	643.2±501.7	1.7±2.3	1.7±0.7	62.8±126.0	87.2±20.0	33.5±4.9
非左室肥厚组	23	765.2±542.0	634.4±501.8	1.6±2.3	1.6±0.4	61.1±26.0	92.4±20.6	35.9±4.2
检验值	?	0.180	0.091	0.570	5.156	0.359	0.069	0.186
P值	?	0.303	0.942	0.814	0.305	0.770	0.285	0.046
组别	例数	甲状旁腺素(ng/L)	血钙(mmol/L)	血磷(mmol/L)	血钾(mmol/L)	血糖(mmol/L)	尿素氮(mmol/L)	收缩压(mmHg)	舒张压(mmHg)
左室肥厚组	66	402.1±295.0	2.2±0.3	1.8±0.7	4.0±0.6	5.0±1.0	19.6±5.6	143.3±17.4	87.1±11.5
非左室肥厚组	23	355.8±405.8	2.2±0.2	1.8±0.6	4.3±0.8	4.9±1.1	19.5±5.4	143.4±17.0	87.6±14.8
检验值	?	0.033	0.299	0.210	0.020	0.730	11.033	0.812	0.460
P值	?	0.559	0.235	0.979	0.131	0.907	0.084	0.997	0.871
组别	例数	TC(mmol/L)	LDL(mmol/L)	心胸比－	LVEF(%)	LVEDD(mm)	LVESD(mm)	LVST(mm)	LVPWT(mm)
左室肥厚组	66	5.2±1.1	3.0±0.9	0.5±0.1	64.0±48.5	62.4±5.4	45.4±7.6	12.5±1.2	11.9±1.4
非左室肥厚组	23	5.9±2.7	3.2±1.2	0.5±0.0	87.0±34.4	48.3±5.3	30.4±4.3	10.3±1.5	9.7±1.4
检验值	?	4.358	3.603	0.343	32.30	0.027	8.995	0.337	0.017
P值	?	0.088	0.431	0.886	0.036	<0.001	<0.001	<0.001	<0.001

表2 不同腹膜转运类型患者的左室肥厚患病情况(χ²＝8.956，P＝0.024)[例(%)]

分组	低转运(n＝7)	低平均转运(n＝38)	高平均转运(n＝28)	高转运(n＝16)	总计
左室肥厚组	4(57.14)	24(63.16)	24(85.71)	14(87.50)	66(74.16)
非左室肥厚组	3(42.86)	14(36.84)	4(14.28)	2(12.50)	23(25.84)

表2 不同腹膜转运类型患者的左室肥厚患病情况(χ²＝8.956，P＝0.024)[例(%)]

分组	低转运(n＝7)	低平均转运(n＝38)	高平均转运(n＝28)	高转运(n＝16)	总计
左室肥厚组	4(57.14)	24(63.16)	24(85.71)	14(87.50)	66(74.16)
非左室肥厚组	3(42.86)	14(36.84)	4(14.28)	2(12.50)	23(25.84)

表3 腹膜透析左室肥厚的相关因素分析

影响因素	r值	P值
NT-proBNP	0.590	<0.001
D/P	0.286	0.007
腹膜转运类型	0.256	0.016
LVEF	－0.222	0.036
LVEDD	0.551	<0.001
LVESD	0.741	<0.001
LVST	0.729	<0.001
LVPWT	0.720	<0.001
LVD	0.676	<0.001

表3 腹膜透析左室肥厚的相关因素分析

影响因素	r值	P值
NT-proBNP	0.590	<0.001
D/P	0.286	0.007
腹膜转运类型	0.256	0.016
LVEF	－0.222	0.036
LVEDD	0.551	<0.001
LVESD	0.741	<0.001
LVST	0.729	<0.001
LVPWT	0.720	<0.001
LVD	0.676	<0.001

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Analysis on correlative factors of left ventricular hypertrophy in patients with peritoneal dialysis

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Analysis on correlative factors of left ventricular hypertrophy in patients with peritoneal dialysis