MHD患者心脏瓣膜钙化与营养状况的相关性分析

目的:分析维持性血液透析(maintenance hemodialysis,MHD)患者心脏瓣膜钙化(cardiac valve calcification,CVC)与营养状况的相关性。方法:选取2019年10月—2020年10月在我院行血液透析且资料完整的MHD患者110例,收集患者的一般临床资料、生化结果,并测量人体学指标,使用MQSGA评分量表评估患者的营养状况,通过多普勒超声心动图评估心脏瓣膜钙化的情况,根据有无瓣膜钙化分为两组,钙化组45例,非钙化组65例,比较两组间临床资料的差异,分析营养状况评分及其他营养相关指标与心脏瓣膜钙化的关系。结果:与非钙化组相比,钙化组MQSGA评分、年龄、透析龄、碱性磷酸酶、血清钙、超敏C反应蛋白水平均显著增高,上臂围、肱三头肌皮褶厚度、血清白蛋白、前白蛋白均显著降低,差异均具有统计学意义(P0.05);Spearman相关性分析显示MQSGA评分(r=0.413,P0.001)与心脏瓣膜钙化呈正相关;肱三头肌皮褶厚度(r=-0.389,P0.001)、血清白蛋白(r=-0.190,P=0.047)与心脏瓣膜钙化呈负相关。logistic回归分析显示影响MHD患者心脏瓣膜钙化的危险因素包括MQSGA评分、年龄、透析龄、肱三头肌皮褶厚度、超敏C反应蛋白。结论:MHD患者心脏瓣膜钙化发生率高;营养不良是维持性血液透析患者心脏瓣膜钙化发生的危险因素。     

维持性血液透析患者胎球蛋白A和炎症水平与心脏瓣膜钙化的相关性

目的 探讨继发性甲状旁腺功能亢进患者行甲状旁腺全切除或次全切除术的预后.方法 入选2009年1月至2014年3月前在青岛大学附属医院血液透析中心的维持性血液透析(maintenance hemodialysis,MHD)患者99例,所有患者均行超声心动检查,根据超声心动结果将患者分为合并心脏瓣膜钙化组和无心脏瓣膜钙化组,另根据心脏瓣膜钙化数量将患者分为无瓣膜钙化(A组)、单个瓣膜钙化(B组)和双瓣膜钙化(C组).采用酶联免疫吸附法(ELISA)检测血胎球蛋白A(Fetuin-A)、白细胞介素6(interleukin-6,IL-6)、超敏C反应蛋白(high sensitivity C-reactive protein,hs-CRP)水平并评价上述指标与心脏瓣膜钙化的相关性.结果 99例患者中合并瓣膜钙化40例(占40.4％),其中二尖瓣瓣膜钙化(mitral valve calcification,MVC)27例(占27.3％),主动脉瓣瓣膜钙化(aortic valve calcification,AVC)30例(占30.3％),二尖瓣瓣膜合并主动脉瓣瓣膜钙化(MVC合并AVC)17例(占17.2％).比较合并瓣膜钙化组和无瓣膜钙化组患者的临床资料发现,合并瓣膜钙化组的年龄、透析时间、血磷、全段甲状旁腺素(intact parathyroid hormone,iPTH)、hs-CRP、IL-6更高,白蛋白、Fetuin-A水平更低.比较A组、B组和C组发现,随着年龄、透析时间的增高,血磷、钙磷乘积、IL-6、hs-CRP水平的增高,瓣膜钙化的数量逐渐增多,而随着血白蛋白、Fetuin-A水平的增高,瓣膜钙化的数量逐渐减少.以Fetuin-A为自变量行相关性分析发现,与年龄(r=-0.246,P=0.014)、透析时间(r=-0.297,P=0.003)、iPTH(r=-0.256,P=0.011)、hs-CRP(r=-0.272,P=0.006)、IL-6(r=-0.492,P=0.000)、心脏瓣膜钙化(r=-0.6,P=0.001)呈负相关,而与血白蛋白(r=0.298,P=0.003)呈正相关.结论 MHD患者心脏瓣膜钙化的发生率较高,以主动脉瓣瓣膜钙化多见.Fetuin-A、炎症水平与心脏瓣膜钙化有着重要的相关性,评估Fetuin-A、炎症水平可能对识别心血管事件特别是心脏瓣膜钙化的发展和恶化有重要价值.     

维持性血液透析患者主动脉钙化相关影响因素分析

目的：探讨维持性血液透析（MHD）患者主动脉钙化的相关影响因素。方法：采用胸部正位X线成像技术检测183例MHD患者主动脉钙化情况,将入选患者分为主动脉钙化组（A组）和主动脉无钙化组（B组）,透析前抽血检测血钙、血磷、全段甲状旁腺激素（iPTH）、C反应蛋白（CRP）和血清白蛋白（Alb）等指标,并计算钙磷乘积,比较两组年龄、透析龄和血清学指标的差异,将上述指标与主动脉钙化进行相关性分析,并对筛选出来的危险因素进行非条件Logistic回归分析。结果：A组和B组在年龄、透析龄、血磷、钙磷乘积和CRP水平方面,差异均有统计学意义（P〈0.01或P〈0.05）;MHD患者主动脉钙化的相关影响因素包括：年龄、透析龄、血磷、钙磷乘积及CRP;Logistic回归分析表明,年龄、透析龄和血磷是主动脉钙化的独立危险因素（P〈0.01）。结论：MHD患者主动脉钙化相当常见,主动脉钙化与年龄、透析龄、钙磷代谢和炎症状态有关。     

维持性血液透析患者血磷波动与心脏瓣膜钙化关系

目的探讨维持性血液透析(maintenance hemodialysis,MHD)患者心脏瓣膜钙化影响因素,及血磷波动与心脏瓣膜钙化的关系。方法回顾性分析2015年6月至2018年6月于武汉大学中南医院血液净化中心规律接受血液透析的110例终末期肾病患者。使用心脏超声检测患者心脏瓣膜钙化情况,分为钙化组及无钙化组,收集患者每三个月复查的血磷,计算其1～3年(4～12次)的波动,使用多因素回归分析探讨其与钙化的关系。结果 110例血液透析患者中,存在心脏瓣膜钙化者51例(46.4%),多因素回归分析显示:年龄(OR=1.100,95%CI:1.051～1.150,P0.001)、透析龄(OR=1.023,95%CI:1.004～1.042,P=0.019)、原发病为糖尿病肾病(OR=3.120,95%CI:1.070～9.101,P=0.037)、血磷(OR=4.923,95%CI:1.664～14.571,P=0.004)为心瓣膜发生钙化的独立危险因素;高磷血症患者钙化率较血磷达标者明显增多(P=0.042),高全段甲状旁腺激素(intact parathyroid hormone,iPTH)患者钙化率较iPTH达标者及低iPTH者明显增多(P=0.015、0.015);进一步分析发现MHD患者3年的血磷波动为心脏瓣膜钙化的独立危险因素(P=0.006)。结论年龄、透析龄、原发病为糖尿病肾病、血磷及血磷波动为瓣膜钙化的独立危险因素,因此控制血磷的同时,应平稳的降血磷,避免血磷波动太大。     

维持性血液透析患者颈动脉钙化相关因素分析

目的：探讨慢性肾衰竭维持性血液透析（MHD）患者颈动脉钙化情况并分析相关因素。方法：对35例MHD患者应用彩色B型超声仪观测双侧颈动脉内膜-中膜厚度（IMT）及钙化情况,同时记录透析龄、收缩压、脉压差,抽血检测血钙、磷、血胆固醇、三酰甘油、白蛋白、C反应蛋白（CRP）、甲状旁腺素,并计算钙磷乘积。结果：35例终末期肾病（ESRD）患者18例（51.4%）存在颈动脉钙化。钙化组IMT值较无钙化组显著增高（P〈0.01）,透析龄、收缩压、脉压差、血磷、钙磷乘积、CRP较无钙化组明显增高（P〈0.05）,而钙化组血浆白蛋白较无钙化组显著降低（P〈0.05）。结论：IMT值、透析龄、血磷、钙磷乘积增高是颈动脉钙化的主要影响因素,收缩压、脉压差、CRP升高和低血浆白蛋白与颈动脉钙化密切相关。MHD患者存在较高的颈动脉钙化率。     

糖尿病肾脏病维持性血液透析患者心脏瓣膜钙化易发因素分析

目的通过检测糖尿病肾脏病(diabetic kidney disease,DKD)患者心脏瓣膜钙化(cardiac valve calcifieation,CVC)情况,对其相关因素进行分析,探讨DKD的易发因素。方法选择2013年1月至2015年12月在我院血液净化中心行维持性血液透析的患者118例,其中DKD患者57例(DKD组),非DKD患者61例(非DKD组),观察2组吸烟比率及年龄有无统计学差异,完善超声心动图、血压、血三酰甘油、血钙、血磷、C反应蛋白、血白蛋白的检测,比较2组之间有无差异,并对DKD组透析时间、血磷、C反应蛋白进行单因素分析。结果 DKD组发生瓣膜钙化44例(占77.2%),非DKD组发生瓣膜钙化24例(占39.3%),2组比较差异有统计学意义(P0.01)。2组患者中单纯主动脉瓣钙化共24例(占20.3%),DKD组17例(占29.8%),非DKD组7例(占11.4%);单纯二尖瓣膜钙化17例(占14.4%),DKD组10例(占17.5%),非DKD组7例(占11.4%);主动脉瓣加二尖瓣同时钙化27例(占22.9%),DKD组17例(占29.8%),非DKD组10例(占16.4%)。2组患者吸烟比率比较差异无统计学意义(P=0.89),2组年龄比较无统计学差异。2组收缩压、舒张压、透析时间、血钙、血磷、钙磷乘积、血三酰甘油比较,差异有统计学意义(P0.05);DKD组收缩压高于非DKD组,舒张压低于非DKD组,透析时间明显短于非DKD组;DKD组血钙、血磷、钙磷乘积明显低于非DKD组,血三酰甘油、C反应蛋白均高于非DKD组,体质量指数、血白蛋白无统计学差异。DKD组CVC的危险因素结果提示透析时间、血磷升高是发生CVC的主要危险因素。结论血钙、钙磷乘积不是DKD瓣膜钙化的预测因子,血磷、血脂、透析时间等是影响瓣膜钙化的独立危险因素。     

维持血液透析患者主动脉弓钙化发生情况及相关因素分析

目的观察维持性血液透析（MHD）患者主动脉弓钙化发生的情况并分析其相关因素。方法观察220例MHD患者胸部正位片主动脉弓钙化的发生情况；将其年龄、性别、原发病、血压、心胸比、血常规及血生化结果与主动脉弓钙化进行相关性分析，比较有钙化组和无钙化组的上述指标。结果82例发生主动脉弓钙化，其中48例透析前已存在主动脉弓钙化,34例透析后（21.15±12.12）月出现。钙化组的年龄、MHD时间、心胸比、钙磷乘积、脉压、球蛋白（G）明显高于非钙化组，全段甲状旁腺激素（iPTH）、白蛋白（A）明显低于非钙化组。结论MHD患者发生主动脉弓钙化的几率很高；影响主动脉弓钙化的因素主要为年龄、脉压、钙磷乘积。     

风湿性心脏病二尖瓣和主动脉瓣胶原变化的研究

目的：研究风湿性心脏病二尖瓣和主动脉瓣瓣膜胶原含量及其类型对瓣膜成形术病例选择的影响。方法：采用羟脯氨酸法测定瓣膜胶原含量的变化,并用十二烷基磺酸钠－聚丙烯酰胺凝胶电泳（SDS－PAGE）分离法测定心瓣膜胶原的类型。结果：正常二尖瓣腱索的胶原含量较瓣叶高＊（P＜0．01）,主动脉瓣胶原含量较二尖瓣低（P＜0．01）,风湿性心脏病患者二尖瓣和主动脉瓣的胶原含量较正常瓣膜有显著性升高（P＜0．01）,正常瓣膜以I型胶原为主,Ⅲ型胶原含量较少,而病变二尖瓣和主动脉瓣其Ⅰ,Ⅲ型,胶原均明显增加,且以I型胶原为主,有钙化的二尖瓣腱索胶原含量高于无钙化瓣膜（P＜0．05）,二尖瓣病变以狭窄为主的病例其二尖瓣腱索的胶原含量较以关闭秒全为主的病例高（P＜0．01）,且二尖瓣瓣叶及腱索的胶含量与二尖瓣口面积呈负相关（r=-0.5431和r=-0.8819,P＜0．01）,结论：风湿性心脏病心瓣膜胶原含量和类型的变化与心瓣膜功能的改变密切相关,瓣膜有无钙化以及二尖瓣病变的性质,可作为施行心瓣膜成形术的选择条件,。     

维持性血液透析患者血清尿酸与心脏瓣膜钙化的关系

目的:探讨MHD患者血清尿酸(serum uric acid,SUA)与心脏瓣膜钙化(cardiac valve calcification,CVC)的关系,为MHD患者CVC的预防、诊断、治疗提供新的理论依据。方法:入选2017年01月~2017年12月在青岛市城阳区人民医院血液净化中心的MHD患者80例作为研究对象。应用超声心动图检测MHD患者CVC的情况,根据主动脉瓣膜、二尖瓣瓣膜或瓣环是否出现1个或多个 1 mm的强回声分为CVC组25例和无CVC组55例。同时检测血常规、碱性磷酸酶、透析前肾功能、透析后肾功能、SUA、血钙、血镁、血磷、C-反应蛋白、β2-微球蛋白、甲状旁腺素等指标。观察两组MHD患者以上指标的变化,分析SUA与其相关性。结果:(1) CVC组与无CVC组性别(χ2=2. 690,P=0. 101)、年龄(t=0. 498,P=0. 620)、透析龄(t=-0. 103,P=0. 917)、尿素下降率(t=-0. 704,P=0. 483)、是否有糖尿病病史(χ2=0. 069,P=0. 792)比较均无统计学差异。(2) MHD患者CVC组SUA(t=2. 845,P=0. 008)、碱性磷酸酶(t=2. 026,P=0. 046)、β2-微球蛋白(t=2. 408,P=0. 018)、血钙(t=2. 048,P=0. 044)、甲状旁腺素(t=2. 083,P=0. 041)水平明显高于无CVC组。(3) MHD患者SUA水平与碱性磷酸酶(r=0. 264,P=0. 018)、β2-微球蛋白(r=0. 294,P=0. 008)、甲状旁腺素(r=0. 373,P=0. 001)呈明显正相关。结论:MHD患者SUA与CVC的发生、发展密切相关,推测可能与其引起钙磷代谢紊乱、上调碱性磷酸酶活性、促发炎症反应等机制有关。     

应用腰椎侧位片评价血液透析患者腹主动脉钙化

目的 应用X线平片腹主动脉钙化评分探讨维持性血液透析( MHD)患者腹主动脉钙化患病率和相关危险因素分析.方法 选取我院资料完整的155例MHD患者为研究对象.通过X线腰椎侧位片检测腹主动脉钙化( AAC)并对其进行评分.结果 155例的腰椎侧位片中,腹主动脉钙化主要发生在第4腰椎节段,并随着节段的上升而逐渐减少.63.63％患者的侧位平片上可见腹主动脉钙化;28.39％患者可见严重腹主动脉钙化(钙化累及3个节段以上).MHD患者的年龄(OR=1.094,P＜0.01)、透析龄(OR=1.013,P=0.022)、血三酰甘油(OR=1.261,P=0.030)和血磷(OR=1.324,P=0.023)水平是发生腹主动脉钙化的独立危险因素,而白蛋白(OR=0.239,P=0.013)为保护性因素.结论 MHD患者腹主动脉钙化患病率高,且与多个血管钙化因素相关.半定量的X线腰椎侧位片方法价格便宜、操作简便,易于临床推广.其对MHD患者的预测价值有待日后更多的随访研究.     

Association of serum FGF23 with abdominal aortic calcification and outcomes in maintenance hemodialysis patients

Objective To explore the association of fibroblast growth factor-23 (FGF23) with abdominal aortic calcification(AAC) and adverse outcomes in maintenance hemodialysis patients. Methods One hundred and fourteen cases of MHD patients were collected prospectively. Serum intact FGF23 was detected by ELISA. Abdomen lateral plain was used as a criteria to determine the abdominal aortic calcification and the abdominal aortic calcification score was counted. Logistic regression analysis was used to determine the risk factors of AAC. Kaplan-Meier analysis was applied to compare the survival rate among different groups and COX regression analysis was used to determine the association of FGF23 and mortality in MHD patients. Results Seventy-six patients present abdominal aortic calcification. The median of AACS was 4.0(0.0, 11.0). The median level of FGF23 was 7277.4(2535.0, 9990.8) pg/ml. The median follow-up duration was 72.0(67.8, 72.8) months. During the follow-up, 22 patients (19.3%) died of all-cause death and 17 cases (14.9%) died of cardiovascular diseases. Serum FGF23 level was positively correlated with AAC (r=0.285, P=0.002). Logistic regression analysis showed that longer age (OR=1.059, 95%CI: 1.020-1.100, P=0.003) and dialysis vintage (OR=1.009, 95%CI 1.000-1.017, P=0.039), smoking history (OR=3.010, 95%CI 1.177-7.696, P=0.021) and higher FGF23 level(OR=2.831, 95%CI 1.010-7.937, P=0.048) were independent risk factors of moderate to severe AAC in MHD patients. Kaplan-Meier survival curves showed that the patients with AACS≥5 had significantly higher all-cause mortality(P=0.028) and CVD mortality (P=0.035) than those with AACS＜5. However, the Kaplan-Meier analysis showed no significant difference regarding the level of serum FGF23 with the all-cause and CVD mortality. Cox regression demonstrated that FGF23 was not associated with increased mortality risk, neither in crude nor in multivariate adjusted models. Conclusions Abdominal aortic calcification had a high prevalence in MHD patients. The all-cause and CVD mortality was higher in patients with moderate to severe AAC. FGF23 was an independent risk factor of moderate to severe AAC, but it can't yet be a predictor for the all-cause and CVD mortality of MHD patients.     

Aortic valve calcification is an independent factor of left ventricular hypertrophy in patients on maintenance haemodialysis.

BACKGROUND: Calcification and dysfunction of aortic and mitral valves are frequently found in chronic dialysis patients, but their influence on the development of left ventricular hypertrophy (LVH) is not well defined. METHODS: Conventional echocardiography and Doppler measurement of trans-aortic flow velocity were performed in 135 chronic haemodialysis patients, and left ventricular mass index (LVMI) and trans-valve pressure gradients were calculated. Average values of systolic, diastolic and pulse pressure (PP), interdialytic weight gain, chronic overhydration (difference between mean post-dialysis and dry weights), plasma calcium, phosphate, haemoglobin, and urea reduction ratio over the year preceding this study were obtained in every patient. RESULTS: Aortic valve calcification was present in 105 patients (78%), associated with stenosis in eight (6%); 39 patients (29%) had aortic regurgitation. Mitral annular calcification occurred in 35 (26%) cases and mitral regurgitation in 45 (33%). LVH was observed in 104 patients (77%). Logistic analysis revealed that only aortic valve calcification predicted LVH. LVMI was higher in patients with aortic valve calcification than in those without calcification: (mean+/-SD) 241+/-52 vs 154+/-64 g/m(2), P=0.001. LVMI was not different between patients with normal, calcified, or regurgitating mitral valves. Patients with aortic valve calcification had higher trans-valve peak flow velocities and pressure gradients than those with non-calcified valves: 1.65+/-0.53 vs 1.37+/-0.33 m/s, P=0.01, and 12.1+/-8.9 vs 7.9+/-3.6 mmHg, P=0.01, respectively. The LVMI correlated directly with both variables (r=0.27 and r=0.24, P<0.005). Stepwise linear regression on nine covariates potentially influencing LVMI (age, body mass index, time on dialysis, systolic blood pressure, PP, chronic overhydration, haemoglobin concentration, trans-aortic flow velocity, and urea reduction ratio) showed that LVMI was independently associated with (i) PP, (ii) haemoglobin (inverse correlation), (iii) peak aortic flow velocity, and (iv) chronic overhydration (r=0.502, R(2)=0.252, ANOVA F-ratio=10.19, P<0.0005). CONCLUSION: Our findings show that aortic valve calcification is associated with LVH in chronic haemodialysis patients, probably because valve resistance to ventricular outflow is increased as shown by trans-aortic flow velocities and pressure gradients. The effect on LVMI is independent of PP, anaemia, and overhydration.     

血液透析患者血清FGF23水平的影响因素及其与矿物质骨代谢异常的关系研究

目的分析维持性血液透析患者血清成纤维细胞生长因子23(FGF23)水平的影响因素,并探究其与矿物质骨代谢异常及血管钙化的关系。 方法2018年1月至2月期间纳入在南方医科大学附属东莞市人民医院进行维持性血液透析3个月以上患者380例,记录其性别、年龄、透析龄、透析充分性及降磷药物使用情况。透析前抽取血清检查钙、磷、全段甲状旁腺素(iPTH)及碱性磷酸酶等矿物质骨代谢指标,以及血红蛋白、白蛋白、血糖、血脂、血清超敏C反应蛋白(hs-CRP)、血清β2微球蛋白等指标。使用酶联免疫吸附法(ELISA)检测血清FGF23,多层螺旋CT进行冠状动脉钙化评分(MSCT)。采用t检验和卡方检验对维持性血液透析患者FGF23的影响因素进行单因素分析,之后使用多元线性逐步回归方法进行多因素分析。 结果本中心维持性血液透析患者血清FGF23中位数水平为8 905.3 ng/L,根据患者的FGF23水平50%中位数将患者分为低水平组(组1)和高水平组(组2)两组。单因素分析结果表明,透析龄、每次透析时间、透析超滤量及使用非含钙降磷药物和透析频次为FGF23水平的影响因素。透析龄更大,每次透析时间长,每周透析次数多、透析超滤量大的患者FGF23水平更高(均P<0.05)。在FGF23水平高于中位数的患者中,尿素氮、血肌酐和血清β2微球蛋白水平更高(均P<0.05)。多元线性回归分析显示,透析龄长和血肌酐升高是FGF23升高的危险因素(均P<0.001)。同时,高FGF23水平与血清钙、血清磷、iPTH水平和高冠状动脉钙化评分相关。 结论透析龄、每次透析时间、透析超滤量、透析频次、尿素氮、血肌酐、血清β2微球蛋白水平与维持血液透析患者FGF23升高有关。透析龄长和血肌酐高是FGF23升高的危险因素。FGF23与维持性血液透析患者矿物质骨代谢和冠状动脉钙化明显相关。     

Conjunctival and corneal calcificationin is associated with abdominal aortic calcification in maintenance haemodialysis patients

Objective To determine the condition of conjunctival and corneal calcificationin in maintenance haemodialysis patients, and explore the relationship between conjunctival and corneal calcificationin (CCC) and abdominal aortic calcification (AAC). Methods CCC was evaluated by slit-lamp eye photographs, and was graded and scored according to Porter’s classification system in the literature. Abdomen 1ateral X-ray examination were used as a criteria to determine the abdominal aortic calcification. The abdominal aortic calcification (AAC) score was calculated. Spearman correlation coefficient was used to analyze the relationship between CCC and AAC. Logistic regression analysis was used to determine the risk factor of CCC in MHD patients. Results Ninety-eight MHD patients were recruited. Their average age and dialysis vintage were (61.89±12.54) years and 51.67 (3.00～192.00) months, ninety-seven patients had conjunctival and corneal calcificationin, and seventy-two patients had abdominal aortic calcification, The median CCC was 8 (0, 17), the median AAC was 6 (0, 20), and the CCC was positively correlated with AAC (r=0.376, P＜0.001). Compared with the patients of CCC score≤5, the patients of CCC score＞10 had a higher level of phosphate, calcium-phosphate product, iPTH, hs-CRP, and longer dialysis vintage, as well as a higher score of AAC (all P＜0.05). Multivariate logistic regression analysis showed that the higher score of AAC and the longer dialysis vintage were independent risk factors for severe corneal calcificationin calcification. Conclusions Conjunctival and corneal calcificationin is common in MHD patients, and CCC is positively associated with AAC, the risk of CCC rises as a result of a severer AAC and a longer dialysis vintage.     

维持性血液透析患者心血管钙化的发生率及相关因素

目的 探讨维持性血液透析患者心血管钙化的发生率及相关因素.方法 选择接受维持性血液透析≥3月的非住院患者60例,完善相关实验室检查,腹部侧位X线片检测腹主动脉钙化评分(Kauppila法),心脏超声检测心脏瓣膜钙化情况,并计算心血管钙化指数.结果 本组患者影像学检查可见钙化的总发生率为68.3％,腹主动脉钙化的患者中5≤腹主动脉钙化评分＜ 16者占41.4％,瓣膜钙化以主动脉瓣为主(占64.5％).有钙化组与无钙化组患者的年龄、血钙、心血管钙化指数存在差异(均P ＜0.05),而透析龄(月)、身高、体质量、握力、血磷、血红蛋白、血清总蛋白、血清白蛋白、血脂未见差异(均P≥0.05).结论 本组患者心血管钙化部位不均衡,随患者年龄和血钙水平的增加,心血管钙化的发生风险升高.     

维持性血透患者颈动脉内膜中层厚度增厚及其影响因素分析

目的研究维持性血透(MHD)患者颈动脉内膜中层厚度(IMT)增厚情况并分析其可能影响因素。方法75例MHD患者为MHD组,30例健康体检者为对照组。采用高频B超检测其颈动脉IMT值,并记录各患者的临床及生化数据。MHD组按IMT值分为正常、异常和增厚3个亚组。对各组数据进行比较并对IMT的各危险因素进行相关性分析。结果MHD组患者颈动脉IMT值明显大于对照组[(1.03±0.42)比(0.63±0.11)mm,P<0.01]。IMT增厚组年龄、收缩压、血浆白蛋白、前白蛋白、胆固醇、血磷水平与IMT正常组相比,差异有统计学意义(P<0.05或P<0.01)。IMT异常组的收缩压、血磷水平明显高于IMT正常组(P<0.01)。单因素相关分析(Model1)结果显示,MHD患者颈动脉IMT与年龄(r=0.247,P=0.032)、收缩压(r=0.758,P<0.01)、血磷(r=0.604,P<0.01)呈显著正相关;与血浆白蛋白(r=-0.292,P=0.011)、前白蛋白(r=-0.681,P<0.01)呈显著负相关。经控制年龄因素后的偏相关分析(Model2)结果与Model1结果一致。多元线性回归分析结果显示高收缩压(B=0.446,P<0.01)、低前白蛋白(β=-0.336,P<0.01)和高血磷(β=0.248,P=0.01)是颈动脉IMT增厚的独立影响因素。结论MHD患者颈动脉IMT明显增厚。高收缩压、低前白蛋白及高血磷是颈动脉IMT增厚的独立危险因素并可能与MHD患者动脉粥样硬化进展相关。     

Cardiac valve calcification as an important predictor for all-cause mortality and cardiovascular mortality in long-term peritoneal dialysis patients: a prospective study

Calcification complications are frequent among long-term dialysis patients. However, the prognostic implication of cardiac valve calcification in this population is not known. This study aimed to determine if cardiac valve calcification predicts mortality in long-term dialysis patients. Baseline echocardiography was performed in 192 patients (mean +/- SD age, 55 +/- 12 yr) on continuous ambulatory peritoneal dialysis (mean +/- SD duration of dialysis, 39 +/- 31 mo) to screen for calcification of the aortic valve, mitral valve, or both. Valvular calcification was present in 62 patients. During the mean follow-up of 17.9 mo (range, 0.6 to 33.9 mo), 46 deaths (50% of cardiovascular causes) were observed. Overall 1-yr survival was 70% and 93% for patients with and without valvular calcification (P < 0.0001, log-rank test). Cardiovascular mortality was 22% and 3% for patients with and without valvular calcification (P < 0.0001). Multivariable Cox regression analysis showed that cardiac valve calcification was predictive of an increased all-cause mortality (hazard ratio [HR], 2.50; 95% CI, 1.32 to 4.76; P = 0.005) and cardiovascular death (HR 5.39; 95% CI, 2.16 to 13.48; P = 0.0003) independent of age, male gender, dialysis duration, C-reactive protein, diabetes, and atherosclerotic vascular disease. Eighty-nine percent of patients with both valvular calcification and atherosclerotic vascular disease, 23% of patients with valvular calcification only, 21% of patients with atherosclerotic vascular disease only, and 13% of patients with neither complication died at 1-yr (P < 0.0005). The cardiovascular death rate was 85% for patients with both complications, 13% for patients with valvular calcification only, 14% for patients with atherosclerotic vascular disease only, and 5% for those with neither complication (P < 0.0005). The number of calcified valves was associated with all-cause mortality (P < 0.0005) and cardiovascular death (P < 0.0005). One-year all-cause mortality was 57% for patients with both aortic and mitral valves calcified, 40% for those with either valve calcified, and 15% for those with neither valve calcified. In conclusion, cardiac valve calcification is a powerful predictor for mortality and cardiovascular deaths in long-term dialysis patients. Valvular calcification by itself has similar prognostic importance as the presence of atherosclerotic vascular disease. Its coexistence with other atherosclerotic complications indicates more severe disease and has the worst outcome.     

4437例瓣膜置换术住院死亡危险因素分析及安贞风险评分系统建立

目的 对4437例心脏瓣膜置换于术病人进行同顺性研究,定量评估住院死亡的危险因素,建立瓣膜置换手术住院死亡风险模型,以及安贞医院瓣膜置换手术风险评分系统.方法 选取安贞医院心脏外科数据库中收录的主动脉瓣置换术病人848例,二尖瓣置换术病人2202例,主动脉瓣、二尖瓣舣瓣膜置换术病人1387例.选取术前.术中33个临床指标作为住院死亡的可能影响因素,利用单因素分析进行筛选,然后利用多因素分析确立3种手术的住院死亡危险因素并建立风险模型.结果经多因素分析,年龄、体表面积、心功能分级、术前肌酐和体外循环时间是主动脉瓣置换术住院死亡的危险因素.心功能分级、术前心衰史、心胸比率、短轴缩短率、病因、左心室收缩末径,体外循环时间和术中1ABP是二尖瓣置换术住院死亡的危险因素.年龄、心功能分级、术前心内膜炎、糖尿病史、既往二尖瓣球囊扩张术,体重指数和体外循环时间是丰动脉瓣、二尖瓣双瓣膜置换术的住院死亡危险因素.ROC曲线下面积分别为主动脉瓣置换术模型0.921(95%CI,0.874～0.967),二尖瓣置换术模型0.859(95%C1,0.813～0.905),主动脉瓣、二尖瓣舣瓣膜置换术模型0.868(95%CI,0.827～0.908).Hosmer-Leme-show检验显示,主动脉瓣置换术模型χ~2=1.463,P=0.993,二尖瓣置换术模型χ~2=8.720,P=0.366,主动脉瓣、二尖瓣双瓣膜置换术模型χ~2=8.134,P=0.420,预计病死率与实际观测病死率差异无统计学意义.结论 3个模型能够定定量评估瓣膜置换术病人住院死亡风险.     

Risk factors for progression of aortic arch calcification in patients on maintenance hemodialysis

Objective To investigate the possible risk factors for the progression of abdominal aortic calcification (AAC) in MHD patients. Methods Total of 170 patients on MHD between June 2014 and October 2014 in the dialysis center of the Second Hospital of Tianjin Medical University were included prospectively. Lateral lumbar radiography were applied to evaluate patients' AAC score (AACs) at baseline and after two-years of follow-up respectively. According to the change of AACs, the patients were divided into rapid AAC progression group and non-rapid AAC progression group. Multivariable Logistic regression models were used to determine the risk factors for the progression of AAC in MHD patients. Results At baseline, the presence of AAC (AACs≥1) was 43.5%(74/170). The mean follow-up duration was 27.6(24.7, 28.0) months. AACs were available in 111 patients, and the presence of AAC was 78.4%(87/111). During the follow up, 36 patients developed new AAC; rapid AAC progression was seen in 54 patients, and non-rapid AAC progression was seen in 57 patients. Multivariate Logistic regression analysis demonstrated that hyperphosphatemia (OR=4.373,95%CI 1.562-7.246, P=0.005) and high density lipoprotein (HDL) (OR=0.031, 95%CI 0.003-0.338, P=0.004)were independent risk factors for AAC progression in MHD patients. Conclusions Hyperphosphatemia and low HDL may promote the progression of AAC. Well-controlled serum phosphate and lipid metabolism may slow the progression of vascular calcification, reducing cardiovascular morbidity and mortality.