不同血液透析方式对维持性血液透析患者心脏舒张功能的影响

目的 探讨2种不同血液透析方式对维持性血液透析（MHD）患者心脏舒张功能的影响.方法 60名无心力衰竭表现的MHD患者分别进入高通量血液透析（HFD）组及普通血液透析（HD）组,每组30例,观察12个月.分别于治疗前（0个月）和治疗后（12个月）测量2组患者左心房内径（LAD）、左心室舒张末期内径（LVDd）、左心室后壁厚度（LVPWT）、室间隔厚度（IVST）、射血分数（LVEF）、二尖瓣血流舒张早期和晚期速度峰值比值（E/A）;二尖瓣环运动峰值早期和晚期速度比值（e＇/a＇）、二尖瓣舒张早期血流峰值与瓣环运动峰值速度比值（E/e＇）,计算左室重量指数（LVMI）.同期检测白蛋白（Alb）、血红蛋白（Hb）、血清钙、磷、甲状旁腺激素（PTH）、25羟维生素D（25-（OH）D3）、成纤维细胞生长因子-23 （FGF-23）、白介素-6（IL-6）、同型半胱氨酸（Hcy）及血压水平.观察2种透析方式对心脏舒张功能及临床指标的影响并进行相关性分析.结果 60例无心力衰竭表现的MHD患者心脏射血分数均正常,舒张功能障碍发生率为80％.钙磷乘积（95％ CI 1.002～1.165,P=-0.048）、LVMI （95％CI 0.952～0.988,P-0.02）和收缩压水平（95％ CI0.981～1.037,P=0.046）是E/e＇的影响因素.HFD组治疗后E/e＇下降（9.99±3.36比11.84±4.88,P＜0.05）,FGF-23 （56.07±26.63pg/ml比85.53±40.54pg/ml,P＜0.01）、钙磷乘积（4.48±1.16mmol^2/L^2比4.96±1.03mmol^2/L^2,P＜0.05）、IL-6 （3.37±2.48pg/ml比5.59±2.53pg/ml,P＜0.05）、Hcy水平（21.13±6.95 μ mol/L比29.40±11.66 μ mol/L,P＜0.01）下降,25-（OH） D3水平（27.3±10.26ng/ml比23.15±10.73ng/ml,P＜0.05）升高,差异均有统计学意义,HD组治疗前后各指标无统计学差异.相关性分析显示,E/e＇与钙磷乘积（r=0.359,P＜0.05）、Hcy（r=0.378,P＜0.05）呈正相关,与FGF-23无相关性.结论 HFD能有效改善MHD患者的左室舒张功能,可能与有效降低钙磷乘积、降低Hcy水平有关;与FGF-23水平降低无相关性.

Different blood purification methods on cardiac diastolic function in maintenance hemodialysis patients

Objective To investigate the effect of two different blood purification methods on cardiac dia- stolic function in maintenance hemodialysis （MHD） patients. Methods Sixty patients without symptoms of heart failure were equally assigned into high-flux hemodialysis （HFD） group or hemodialysis （HD） group, and were observed for 12 months. Left atrial diameter, left ventricular end-diastolic diameter, interventricular sep- tal thickness, left ventricular posterior wall thickness, left ventricular ejection fraction （LVEF）, mitral diastolic early and late maximum blood flow velocity ratio, mitral early diastolic peak velocity, peak velocity ratio and diastolic annulus early exercise, diastolic mitral early and late diastolic annulus movement peak velocity ratio （E/e＇） were measured before treatment （0 month） and after the treatment for 12 months （12 months）. Left ven- tricular mass index （LVMI） was calculated. Hemoglobin, serum phosphorus, calcium, albumin, fibroblast growth factor -23 （FGF-23）, 25-hydroxyl vitamin D, parathyroid hormone, homcysteine （Hcy） and interleukin- 6 （IL-6）, and blood pressure were simultaneously measured. The influence of the two hemodialysis methods on cardiac diastolic function and clinical parameters were analyzed. Results In the 60 patients, LVEF was all normal but cardiac diastolic dysfunction was found in 80% of the patients. The factors that influence E/e＇ ratio were calcium-phosphorus product （95% CI 1.002± 1.165, P=0.048）, LVMI （95% CI 0.952±0.988, P=-0.02）, and systolic blood pressure （95% CI 0.981±1.037, P=0.046）. In HFD group after the treatment, E/e＇ ratio decreased significantly from 4.884-11.84 to 3.364-9.99 （P〈O.05）, serum FGF-23 from 40.54±85.53 to 26.634- 56.07pg/ml （P〈0.01）, calcium-phosphorus product from 1.03 4-4.96mmol^2/L^2 to 1.16 4.4.48mmol^2/L^2 （P〈 0.05）, Hcy from 11.66±29.40gmol/L to 6.95±21.13μmol/L （P〈0.01）, and IL-6 from 2.53-4-5.59pg/ml to 2.48± 3.37pg/ml （P〈0.05）, but 25-（OH） D3 increased from 10.73-4-23.15ng/ml to 10.264-27.3 ng/ml （P〈0.05）. In contrast in HD group, these parameters did not change significantly. Correlation analyses of the data in HFD group indicated that E/e＇ ratio was positively correlated with calcium-phosphorus product （r= 0.359, P〈0.05） and Hcy （r = 0.378, P〈0.05）, but was unrelated to serum FGF-23 （P〉0.05）. Conclusions HFD can effec- tively improve cardiac diastolic dysfunction in MHD patients. The improvement may relate to the decrease of calcium-phosphate product and Hcy, but may not relate to the decrease of serum FGF-23 .