维持性血液透析的尿毒症患者心脏结构及功能改变相关因素分析

发布时间：2018-04-28 22:27

本文选题：血液透析 + 尿毒症　；参考：《吉林大学》2014年硕士论文

【摘要】：背景：终末期肾病在全世界的发病率呈增高趋势，且病程长，治疗花费高，给个人及社会造成了巨大的负担，现已然成为重要的公共医疗问题。血液透析作为ESRD患者的主要肾脏替代治疗方法之一，近年来尽管在技术上取得了飞速的进步，但MHD患者的长期生存率和生活质量仍然不高，且各种急慢性并发症较多。其中不良心血管事件作为MHD患者的各系统并发症之一，严重影响患者的预后。目的：通过对MHD患者进行心脏超声检查，发现有心脏结构及功能变化者，并对影响其发生发展的相关因素进行分析，从而方便在临床上对于相关因素进行有效的干预，以提高MHD患者的长期存活率及生活质量。方法：选取2013年1月至2014年1月于吉林大学第一医院肾病科行维持性血液透析并进行心脏超声检查的患者。筛选出符合标准的MHD患者（年龄≥18岁，透析龄＞3个月；排除既往有原发性心脏疾病、肿瘤疾病及近期发生急性感染的患者）178例。按照心脏彩超提示的有无心脏改变，，将研究对象分为有心脏改变及无心脏改变两组。记载每组患者的一般资料、相关生化指标及心脏超声结果。运用SPSS18.0软件进行数据的统计分析。计数资料组间比较采用卡方检验；计量资料符合正态分布的组间比较采用t检验，不符合正态分布的组间比较采用非参数检验，P＜0.05表示差异有统计学意义。两组研究指标进行上述比较后，将差异有统计学意义的相关指标进行多因素logistic回归分析，被回归方程接受者为影响心脏结构及功能的独立危险因素。对于上述独立危险因素诊断心脏改变的方法绘制Roc曲线，从而得出每种危险因素对心脏结构及功能变化有意义的最佳临界值（灵敏度，特异度）及相对应的曲线下面积（area under curve，AUC）。AUC可代表诊断的准确性，AUC越大，诊断的准确性越高。应用与研究心脏改变相关因素相同的方法，分析心脏改变中发生率最高的左室舒张功能减退的相关因素。结果：178例维持性血液透析患者中，发生心脏结构及功能改变者共120例，占总人数的67.4%。其中发生左室舒张功能减退者最多，共96例，占总人数的53.9%。应用相关检验方法比较后，透析龄、铁蛋白、血磷、及钙磷乘积的差异有统计学意义（P＜0.05）。将以上指标建立多因素Logistic回归方程，其中透析龄、铁蛋白及血磷被回归方程接受，表明上述三个指标高皆为MHD患者心脏结构及功能改变的独立危险因素。进一步对以上三个指标预测心脏改变的诊断方法绘制ROC曲线，得出诊断心脏改变的最佳临界值，透析龄36.00个月（灵敏度0.850，特异度0.655），AUC0.859；铁蛋白：420.00ug/L（灵敏度0.917，特异度0.469），AUC0.729；血磷:1.74mmol/L（灵敏度0.950，特异度0.655），AUC0.782。收缩压高为MHD患者发生左室舒张功能减退的独立危险因素。对收缩压预测左室舒张功能减退的诊断方法绘制ROC曲线，得出诊断左室舒张功能减退的最佳临界值为137.50mmHg （灵敏度0.813，特异度0.561），AUC0.737。结论：维持性血液透析患者心血管疾病的患病率较高，其中发生左室舒张功能减退者最多。高透析龄、高铁蛋白及高血磷皆为MHD患者心脏改变的独立危险因素。MHD患者透析龄≥36.00个月、铁蛋白≥200ug/L或血磷≥1.74mmol/L皆可作为预测心脏改变的方法，且这两种诊断方法均有一定的准确性，其正确判断心脏改变的百分率分别为：85.0%、91.7%、95.0%；正确判断非心脏改变的百分率分别为：65.5%、46.9%、65.5%。收缩压高为MHD患者左室舒张功能减退的独立危险因素。MHD患者收缩压≥137.50mmHg可作为诊断左室舒张功能减退的方法，此种方法有一定的准确性，其正确判断左室舒张功能减退的百分率为81.3%；正确判断非心脏改变的百分率分别为：56.1%。
[Abstract]:Background: the incidence of end-stage renal disease is increasing in the world, with a long course of disease, a high cost of treatment and a huge burden on individuals and society. It has become an important public medical problem. Hemodialysis is one of the major renal replacement therapies for ESRD patients. In recent years, rapid progress has been made in technology, However, the long-term survival rate and quality of life of MHD patients are still not high, and there are many acute and chronic complications. The adverse cardiovascular events, as one of the systemic complications of MHD patients, seriously affect the prognosis of the patients.
Objective: through the echocardiographic examination of MHD patients, the changes of cardiac structure and function were found and the related factors affecting their development were analyzed so as to facilitate the effective intervention of the related factors in clinical practice so as to improve the long-term survival rate and the quality of life of the patients with MHD.
Methods: from January 2013 to January 2014, patients with maintenance hemodialysis and echocardiography in Department of nephropathy of No.1 Hospital of Jilin University were selected to select MHD patients (age 18 years old, dialysis age > 3 months), and 178 patients with primary heart disease, swelling disease and recent acute infection were excluded. Two groups were divided into two groups: heart change and no heart change. The general data of each group, related biochemical indexes and cardiac ultrasound results were recorded. Statistical analysis of data was carried out by SPSS18.0 software. T test was used in the comparison of states distribution, and non parametric tests were used in groups that did not conform to normal distribution, and P < 0.05 indicated that the difference was statistically significant. The two groups of research indicators carried out multiple factors logistic regression analysis with statistically significant correlation indexes, and the recipients of the regression equation affected the heart structure. The independent risk factors of the function. Draw the Roc curve for the above independent risk factors for the diagnosis of cardiac changes, thus obtaining the best critical value (sensitivity, specificity) and the area under the corresponding curve (area under curve, AUC).AUC for the diagnostic accuracy of each risk factor, AUC. AUC The more accurate, the higher the accuracy of the diagnosis. The same method used to study the related factors of heart change was used to analyze the related factors of the highest incidence of left ventricular diastolic dysfunction in cardiac changes.
Results: among the 178 patients with maintenance hemodialysis, there were 120 cases of cardiac structure and function change, which accounted for the largest number of 67.4%. in the total number of left ventricular diastolic dysfunction, which accounted for 96 cases, which accounted for the total number of 53.9%..
The differences in age, ferritin, blood phosphorus, and calcium and phosphorus products were statistically significant (P < 0.05). The above index was used to establish a multiple factor Logistic regression equation, in which the age of dialysis, ferritin and blood phosphorus were accepted by the regression equation, indicating that the above three indexes were all independent of the changes of cardiac structure and function in MHD patients. Risk factors. Further the ROC curve was plotted for the diagnosis of cardiac changes by the above three indicators, and the best critical value for the diagnosis of cardiac changes, 36 months of dialysis age (sensitivity 0.850, specificity 0.655), AUC0.859; ferritin: 420.00ug/L (sensitivity 0.917, specificity 0.469), AUC0.729; blood phosphorus: 1.74mmol/L (sensitivity 0.950) Degree 0.655), AUC0.782.
An independent risk factor for the onset of left ventricular diastolic dysfunction in MHD patients. The ROC curve was plotted for the diagnostic method of systolic pressure to predict left ventricular diastolic dysfunction, and the best critical value for the diagnosis of left ventricular diastolic dysfunction was 137.50mmHg (sensitivity 0.813, specificity 0.561), AUC0.737.
Conclusion: the incidence of cardiovascular disease in patients with maintenance hemodialysis is higher, among which left ventricular diastolic dysfunction is the most. High dialysis age, high ferritin and high blood phosphorus are the independent risk factors of cardiac change in MHD patients. The dialysis age of patients with.MHD is more than 36 months. Ferritin > 200ug/L or blood phosphorus more than 1.74mmol/L can be used as predictive heart. The two methods of diagnosis were accurate, and the percentage of correct judgments of cardiac changes were 85%, 91.7%, 95%, and the percentage of non cardiac changes was 65.5%, 46.9%, 65.5%., respectively.
The independent risk factor for left ventricular diastolic dysfunction in MHD patients with systolic and diastolic dysfunction.MHD patients with systolic pressure more than 137.50mmHg can be used as a diagnostic method for left ventricular diastolic dysfunction. This method has certain accuracy. The percentage of the correct judgement of left ventricular diastolic dysfunction is 81.3%; the percentage of non cardiac changes is correctly judged to be 56 .1%.

【学位授予单位】：吉林大学
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：R692.5

【参考文献】