超声心动图评价尿毒症患者肾移植术后左室重构及功能改变的临床研究

发布时间：2018-03-26 03:01

  本文选题：尿毒症　切入点：超声　出处：《华中科技大学》2014年博士论文

【摘要】：前言 多种慢性肾脏疾病终末期表现为尿毒症,其显著增加并发心血管疾病和死亡的风险。心血管事件是尿毒症患者死亡的首要原因,约58%的慢性肾脏疾病患者死于心血管疾病,常见为心源性猝死及心衰。心脏重构为心肌受损或心脏负荷增加所导致心脏大小、形状及功能改变。左室肥厚是慢性肾脏疾病患者最常见的心血管并发症之一,往往预示预后较差。临床上75%成人尿毒症患者开始透析时有左室肥厚。尿毒症时心脏病理学改变包括纤维化、肥厚、心肌组织冠脉灌注减少。 目前尿毒症的治疗方式主要为肾移植和透析。与透析治疗相比,肾移植治疗能明显降低死亡率,被认为是终末期慢性肾脏病的标准治疗。Dzemidzic等认为,移植后左室质量减少与尿毒症相关危险因素减少有关。评价肾移植术后左室质量变化对评估患者预后有重要临床意义,然而,对于肾移植术后左室质量是否减少目前仍存在争议。早期研究表明肾移植术后心功能明显改善、左室肥厚减轻。Montanaro等认为肾移植术后左室质量减少,而Patel等研究表显示肾移植术后左室质量无明显变化。近期Vaidya等研究认为,移植后大部分患者左室质量减少,仍有少数患者左室质量无明显变化,并提出左室质量减少程度与术前肥厚程度相关。 肾移植较维持性血液透析者有更高的生存率,USRDS数据表明,接受肾移植的患者死亡率明显较接受常规透析患者低。然而,肾移植患者每年遭受非致死性心血管事件的发生率是一般人群的50倍,死于心功能不全的发生率是一般人群的10倍。相关研究指出,移植术后收缩功能不全患者心血管事件死亡率较收缩功能正常肾移植患者增加,因此,评价尿毒症患者肾移植术后左室收缩功能有重要意义。 临床上评估左室结构及功能的技术有磁共振成像、放射性核素、心血管造影、CT、心导管及超声心动图等。磁共振成像被认为是评价左室结构及功能的金标准,但是其检查费用昂贵、检查时间长,有一定的禁忌症,限制了其在临床上广泛应用；放射性核素、心血管造影、心导管检查具有侵袭性；CT检查具有放射性。超声心动图由于其具有无创、无放射性、价廉、可重复检查等优点,在临床作为监测心脏形态结构和功能的首选检查手段,不仅能够清晰观察心脏的结构,而且还能评价心脏的功能。本研究目的旨在应用二维超声心动图和斑点追踪技术对肾移植术后左室结构及功能进行监测,探讨肾移植术后左室结构和功能的改变,从而为临床提供更大的帮助。 本研究分为以下三部分： 第一部分：尿毒症患者左室重构与收缩功能的超声评价 本部分以67例尿毒症作为研究对象,根据左室射血分数(EF)分为EF正常组(47例)和EF减低组(20例)。获取左室长轴切面,应用二维超声心动图测量并计算舒张末期左室内径(LVEDD)、舒张末室间隔厚度(IVST)。舒张末左室后壁厚度(PWT)、左室质量(LVM)、左室质量指数(LVMI)。应用双平面Simpson法计算左室射血分数(EF)。获取左室乳头肌短轴切面、心尖四腔切面应用斑点追踪成像(STI)技术测量并记录左室整体环向收缩期峰值应变(GCS)、径向收缩期峰值应变(GRS)、纵向收缩期峰值应变(GLS)。探讨尿毒症患者左室结构及收缩功能改变。结果①与对照组相比,尿毒症患者收缩压、舒张压、脉压,心率增高,其中EF减低组较EF正常组心率增快,收缩压增高,差异有统计学意义(P0.05)。②与对照组比较,尿毒症患者LVEDD扩大,IVST、PWT增厚,LVM及LVMI增大,且EF减低组较EF正常组改变更明显,差异有统计学意义(P0.05)。③与对照组相比,尿毒症组GCS、GRS、GLS均减低,并且EF减低组左室应变测值较EF正常组进一步减低,差异有统计学意义(p0.05)。 第二部分尿毒症患者肾移植术后左室重构的超声评价 本研究以30例肾移植患者为研究对象,于术前、术后3月、术后6月、术后12月进行超声检查,二维超声心动图测量并计算左室参数：舒张末期左室内径(LVEDD)、舒张末室间隔厚度(IVST)、舒张末左室后壁厚度(PWT)、左室质量(LVM)、左室质量指数(LVMI)。应用双平面Simpson法计算左室射血分数(EF)。结果①尿毒症患者收缩压、舒张压、脉压于术后3个月、6个月、12个月较术前明显减低至正常对照组水平,差异有统计学意义(P0.05)；EF术后3个月、6个月、12个月较术前增高至正常对照组水平,差异有统计学意义(P0.05)。②尿毒症患者IVST、PWT、LVEDD、 LVM、 LVMI术后3个月、6个月、12个月均较术前减小,差异有统计学意义(P0.05)。③LVMI与SBP (r=0.734, p=0.000)、DBP (r=0.550,p=0.015)、PP (r=0.507, p=0.027)、血肌酐(r=0.539,p=0.017)成正相关,与动静脉瘘(r=-0.071,p=0.774)、术前透析时间(r=-0.008,p=0.975)、术前EF(r=-0.327,p=0.171)无关。多元回归分析表明收缩压是尿毒症患者术后LVMI的独立预测因素(β=0.734,p=0.000)。 第三部分STI技术评价尿毒症肾移植术后患者左室整体收缩功能 本研究以30例肾移植患者为研究对象,于术前、术后3月、术后6月、术后12月进行超声检查,获取左室乳头肌短轴切面、心尖四腔切面应用斑点追踪成像(STI)技术测量并记录左室整体环向收缩期峰值应变(GCS)、径向收缩期峰值应变(GRS)、纵向收缩期峰值应变(GLS)。三维超声心动图测量左室射血分数(EF)。结果①与对照组比较,尿毒症患者术前EF、GCS、GRS、GLS减低,差异有统计学意义(p0.05)；EF术后6个月、12个月较术前增加至对照组水平,差异有统计学意义(p0.05),术后3个月与术前比较差异无统计学意义；GCS、GRS、GLS术后3个月、6个月、12个月较术前增加,但低于对照组,差异有统计学意义(p0.05)。③GCS、GCS、GLS与SBP、DBP、PP、Cr、透析时间、AVF呈负相关。 结论 1、尿毒症患者左室发生重构,左室收缩功能减低,超声斑点追踪成像技术可早期发现左室射血分数正常尿毒症患者左室收缩功能不全。 2、肾移植可改善尿毒症患者左室结构、质量及收缩功能,随着术后时间延长,左室结构、质量及收缩功能逐渐恢复,但仍较正常人有差异。移植术后LVMI与血压、血肌酐水平相关。收缩压是肾移植术后LVMI改变的预测因子。左室收缩功能与血压、血肌酐、透析时间、AVF相关。 3、超声技术作为评价尿毒症患者肾移植术后左室结构和功能改变的随访工具。
[Abstract]:Preface
A variety of end-stage chronic kidney disease manifestations of uremia, significantly increased the risk of death and cardiovascular disease. Cardiovascular events are the leading cause of death in patients with uremia in patients with chronic kidney disease, about 58% died from cardiovascular disease, common for sudden cardiac death and heart failure. Cardiac remodeling for myocardial injury or cardiac load resulting in increased heart size change, shape and function. Left ventricular hypertrophy is one of the most common cardiovascular complications in patients with chronic kidney disease, often indicates poor prognosis. Clinically, 75% adult patients with uremia started dialysis with left ventricular hypertrophy. Uremic heart pathological changes including fibrosis, myocardial hypertrophy, coronary perfusion tissue decreased.
At present, the major treatment for uremic renal transplantation and dialysis. Compared with dialysis, kidney transplantation can significantly reduce mortality, considered end-stage chronic kidney disease treatment of standard.Dzemidzic think that the loss associated with uremia related risk factors of left ventricular mass reduction after transplantation. Evaluation after renal transplantation on left ventricular mass change to evaluate the prognosis of patients has important clinical significance, however, for after kidney transplantation reduces left ventricular mass is still controversial. Early studies showed that cardiac function after renal transplantation significantly improved left ventricular hypertrophy, reduce the.Montanaro that reducing left ventricular mass after renal transplantation, and Patel on the table shows no significant changes in left ventricular quality after renal transplantation. The recent Vaidya studies suggest that most patients with reduced left ventricular mass after transplantation, there is still a small number of patients with left ventricular mass did not change significantly, and the left ventricular mass The degree of reduction was related to the degree of preoperative hypertrophy.
Kidney transplantation with maintenance hemodialysis patients had a higher survival rate, USRDS data showed that the mortality of patients undergoing renal transplantation was significantly higher than routine dialysis patients is low. However, the annual renal transplant patients suffered non fatal cardiovascular events rate is 50 times that of the general population, died of heart failure incidence is 10 times that of the general population. The study pointed out that after transplantation contraction dysfunction in patients with cardiovascular mortality than systolic function in normal renal transplant patients increased, therefore, the left ventricular systolic function assessment in renal transplantation has important significance.
The clinical evaluation of left ventricular structure and function of the technology of magnetic resonance imaging, radionuclide angiocardiography, CT, cardiac catheterization and echocardiography. Magnetic resonance imaging is considered the gold standard for assessment of left ventricular structure and function, but the examination cost is expensive, check for a long time, there are some contraindications, limit it is widely used in clinic; radionuclide angiography, cardiac catheterization, aggressive; CT examination is radioactive. Echocardiography because it is non-invasive, non radioactive, inexpensive, reproducible inspection etc., as the preferred method for examination of the morphology and function of cardiac monitoring in clinic, not only can clearly observe the heart the structure, function and also to evaluate the heart. The purpose of this study is to use two-dimensional echocardiography and speckle tracking technology to monitor the structure and function of left ventricular in patients after renal transplantation of kidney The changes in the structure and function of the left ventricle after transplantation provide greater help to the clinic.
This study is divided into the following three parts:
The first part: echocardiographic evaluation of left ventricular remodeling and systolic function in patients with uremia
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