甲状腺素片补充治疗对慢性肾脏疾病患者甲状腺激素水平的影响研究

目的 探讨小剂量甲状腺素补充治疗对慢性肾脏疾病患者的甲状腺激素水平、营养不良及左心功能的影响.方法 湖南省人民医院2013年2月至2015年2月间收治的慢性肾脏疾病患者210例,A组为eGFR＜ 15mL ·(min·1.73m2)-1的患者(n=70),B组为15＜ eGFR＜30mL·(min·1.73m2)-1的患者(n=70),C组为30 ＜eGFR ＜60mL·(min·1.73m2)-1的未透析患者(n=70).选择同期本院体检的正常人群为正常对照组(D组,n =70).收集4组患者血液、生化临床资料,检测游离三碘甲状腺原氨酸(free triiodothyronine,FT3)、游离甲状腺素(freethyroxine,FT4)、促甲状腺激素(thyroid stimulating hormone,TSH)、C反应蛋白(C reactive protein,CRP)、左心室射血分数(left ventricular ejection fraction,LVEF)及左心室质量指数(Left ventricular mass index,LVMI),并计算主观综合性营养评估法(subjective global assessment of nutritional act,SGA)等指标.每组根据甲状腺激素水平分为正常组Ⅰ、异常组Ⅱ,观察各组间各指标差异,再给予异常组小剂量甲状腺激素干预后观察各项指标改变.结果 A、B、C组FT3均显著低于D组(P＜0.05),低T3综合征的发生率随eGFR下降而升高;正常组Ⅰ与异常组Ⅱ相比,ALB、CRP、SGA、LVEF、LVMI比较有显著差异(P＜0.05);异常组的FT3与eGFR、SGA、ALB、LVEF呈显著正相关(r=0.912,P＜0.001;r =0.721,P＜0.001;r =0.810,P＜0.001;r=0.903,P＜0.001);FT3与CRP、LVMI呈负相关(r=-0.981,P＜0.001;r=-0.442,P＜0.001);异常亚组给予小剂量甲状腺素治疗后FT3及LVEF较治疗前明显改善(P＜0.05),治疗后eGFR水平只有C2组患者有提高(P＜0.05).结论 甲状腺素水平下降与肾功能严重程度相关,以血清FT3水平降低为主;低水平FT3与营养、左心功能有显著相关性;予以小剂量的甲状腺激素治疗后的低T3及亚临床甲减者的左心收缩功能有提高,中度肾功能损伤的患者eGFR有提高.

The effect of thyroxin tablet on thyroid hormone level changes in patients with chronic kidney disease

Objectives To investigate the effect of thyroid hormone on thyroid hormone level,malnutrition and left heart function in patients with chronic kidney disease(CKD).Methods 210 patients with chronic kidney disease in our hospital from February 2013 to February 2015 were selected,Group A:patients with CKD eGFR ＜ 15mL · (min · 1.73 m2)-1] (n =70),Group B:patients with CKD 15 ＜ eGFR ＜ 30mL · (min · 1.73m2)-1] (n =70),Group C:patients with CKD 30 ＜ eGFR ＜60mL · (min · 1.73m2)-1] (n =70),Group D:healthy examinees during the same period in our hospital were selected as control group (n =70).The free triiodothyronine (FT3),free thyroxine (FT4),thyroid stimulating hormone (TSH),hemoglobin (Hb),serum albumin (ALB),total cholesterol (TC),triglyceride (TG),serum creatinine (SCr),C-reactive protein (CRP) and left ventricular ejection fraction (LVEF),left ventricular mass index (LVMI),subjective global assessment of nutritional act(SGA) and other indicators were detected in four groups.Patients in group A、B、C were divided into two sub-groups according to thyroid hormone levels:group 1 (normal thyroid level) and group 2 (abnormal).And the administration of small dose of thyroid hormone was given to patients in group 2,the effect of the administration was evaluated by the above indexes.Results The FT3 in group A 、B and C were significantly lower than that in group D (P ＜ 0.05).The incidence of low T3 syndrome rose with eGFR decline.There were significant differences of levels of ALB、CRP、SGA、LVEF、LVMI between group 1 and group 2,and the FT3 level in group 2 was significant correlated with eGFR,SGA,ALB,LVEF(r=0.912,P ＜0.001;r=0.721,P ＜0.001;r=0.810,P ＜0.001;r =0.903,P ＜ 0.001),negatively correlated with CRP,LVMI was(r =-0.981,P ＜ 0 001;r =-0.442,P ＜ 0.001).After treated with small dose of thyroid hormone,FT3 and LVEF were improved while FT4,TSH,ALB,SGA,CRP,LVMI were not improved in group 2.eGFR level was improved only in group C2 (P ＜ 0.05).Conclusions Serum T3 levels were associated with severity of CKD.Small doses of thyroid hormone therapy had an impact on left ventricular systolic function in CKD patient with low T3 and subclinical hypothyroidism,eGFR improvement in patients with moderate renal impairment.