肾功能损伤对N末端B型利钠肽原应用于心力衰竭诊断的影响

发布时间：2018-07-05 03:11

本文选题：心力衰竭 + N末端B型利钠肽原　；参考：《青岛大学》2017年硕士论文

【摘要】：目的探讨不同肾功能损伤程度下氨基末端B型利钠肽原用于诊断心力衰竭的价值;根据肾功能状态分层界定NT-proBNP用于诊断心力衰竭的截断值;利用Meta分析评价根据肾功能的损伤情况分层界定NT-proBNP用于诊断心力衰竭的截断值的准确性。方法:选取年龄在50~75岁之间的心血管疾病患者420例,根据左室射血分数(LVEF)将纳入研究的患者分为心功能正常组(LVEF≥40%,n=232)和心力衰竭组(LVEF40%,n=188),再按估测的肾小球滤过率(e GFR)将两组均进一步分为肾功能正常亚组[e GFR≥90 ml/(min·1.73 m~2)]、肾功能轻度损伤亚组[90e GFR≥60 ml/(min·1.73 m~2)]、肾功能中度损伤亚组[60e GFR≥30ml/(min·1.73 m~2)]及肾功能重度损伤亚组[e GFR30 ml/(min·1.73 m~2)4个亚组。观察不同亚组中血清NT-proBNP水平的变化及应用其诊断心力衰竭的最佳截断值。从Pub Med、Web of Science、Science Direct、Cochrane Library、中国知网、万方、维普、中国生物医学文献数据库中检索关于肾功能正常与肾功能不全患者在合并心力衰竭时血清NT-proBNP水平变化的随机对照试验,检索时间均从建库至2016年4月,纳入符合入选标准的文献进行Meta分析。结果:心力衰竭组患者血清NT-proBNP水平明显高于心功能正常组(P0.05);血清NT-proBNP水平与e GFR呈显著负相关性(相关系数分别为:总样本r=㧟0.664;心力衰竭组r=㧟0.721;心功能正常组r=㧟0.686,P0.05);在心功能正常组中,与肾功能正常亚组比较,肾功能轻度损伤亚组患者的NTproBNP无明显升高(P0.05),肾功能中度损伤亚组与肾功能重度损伤亚组患者的血清NT-proBNP水平均明显升高(P0.05);在心力衰竭组中,仅肾功能重度损伤亚组患者血清NT-proBNP水平较其他亚组显著升高(P0.05);肾功能正常或轻度损伤时NT-proBNP诊断心力衰竭的最佳截断值为1070pg/mL(敏感性为91.8%,特异性为72.6%),肾功能中度损伤时诊断的最佳截断值为7121pg/mL(敏感性为80.2%,特异性为89.7%),肾功能重度损伤时诊断的最佳截断值为33344pg/mL(敏感性为83.3%,特异性为80.0%)。其最佳曲线下面积(AUC)分别为0.899、0.714、0.825。肾功能不全的心力衰竭患者血清NT-proBNP水平较肾功能正常的心力衰竭患者明显升高,差异具有统计学意义(SMD=㧟0.90,95%CI[㧟1.04,㧟0.75],P0.01);无肾功能损伤与轻度肾功能损伤比较、轻度肾功能损伤与中度肾功能损伤比较、中度肾功能损伤与重度肾功能损伤比较,后者血清NT-proBNP水平均较前者高,且差异均有统计学意义(SMD=㧟0.52,95%CI[㧟0.86,㧟0.19],P0.01;SMD=㧟0.84,95%CI[㧟1.15,㧟0.52],P0.01;SMD=㧟0.95,95%CI[㧟1.43,㧟0.47],P0.01)结论:肾功能中、重度损伤会影响循环中NT-proBNP水平,心力衰竭患者在合并肾功能损伤时,血清NT-proBNP水平将明显升高,且与肾功能损伤的程度呈正相关;在肾功能损伤情况下,应用NT-proBNP诊断心力衰竭的截断值应该相应提高;NT-proBNP诊断心力衰竭的准确性在于它的高阴性预测值,所界定的截断值能有效地排除心力衰竭,提高诊断率,减少漏诊,而由于受多种因素的影响,其特异性较差。意义:本研究结果及结论提示:肾功能状态会影响循环中NT-proBNP的水平,当合并肾功能中、重度损伤时,心力衰竭患者血清NT-proBNP水平显著升高。因此,在应用N proBNP诊断心力衰竭时要充分考虑到肾功能状态的影响。根据肾功能损伤程度分层界定NT-proBNP用于诊断心力衰竭的截断值,可以更准确地诊断合并有肾功能损伤的心力衰竭,对临床心力衰竭的诊断有着重要的意义。
[Abstract]:Objective to explore the value of amino terminal B natriuretic peptide for diagnosis of heart failure with different renal function injuries, and to define the truncated value of NT-proBNP in diagnosis of heart failure according to the stratification of renal function, and to evaluate the diagnostic accuracy of the truncated value of NT-proBNP for the diagnosis of heart failure based on Meta analysis. Methods: 420 patients aged 50~75 years were selected and divided into normal cardiac function group (LVEF > 40%, n=232) and heart failure group (LVEF40%, n=188) according to the left ventricular ejection fraction (LVEF), and then the two groups were further divided into [e GFR in the normal subgroup of renal function according to the estimated glomerular filtration rate (E GFR). 90 ml/ (min. 1.73 m~2)], mild renal injury subgroup [90e GFR > 60 ml/ (min. 1.73 m~2)], 4 subgroups of renal function moderate injury [60e GFR > 30ml/ (min. 1.73)) and renal function severe injury subgroup 4 subgroups. Optimal truncation value. From Pub Med, Web of Science, Science Direct, Cochrane Library, Chinese knowledge network, Wanfang, VP, Chinese biomedical literature database, a randomized controlled trial on the changes in serum NT-proBNP levels in patients with normal renal function and renal failure in patients with congestive heart failure was retrieved from the establishment to April 2016. The serum NT-proBNP level of patients with heart failure was significantly higher than that of normal cardiac function group (P0.05), and the serum NT-proBNP level was negatively correlated with e GFR (the correlation coefficient was the total sample r=? 0.664; cardiac failure group r=? 0.721; cardiac function normal group r=? 0.686, P0.05); in cardiac function. In the normal group, compared with the normal subgroup of renal function, the NTproBNP was not significantly increased in the subgroup of mild renal impairment subgroup (P0.05). The serum NT-proBNP water in the subgroup of renal function moderate injury and the severe renal damage subgroup increased significantly (P0.05); in the heart failure group, the serum NT-proBNP water in the subgroup of the renal function severe injury subgroup was only NT-proBNP water. The best truncated value of NT-proBNP in the diagnosis of heart failure was 1070pg/mL (sensitivity 91.8%, specificity 72.6%), and the best truncation value of the diagnosis of renal function moderate injury was 7121pg/mL (sensitivity 80.2%, specificity 89.7%), and the diagnosis of renal function severe injury. The optimal truncation value was 33344pg/mL (sensitivity 83.3%, specificity 80%). The level of NT-proBNP in patients with heart failure with 0.899,0.714,0.825. renal insufficiency (AUC) was significantly higher than that of normal renal failure patients (SMD=? 0.90,95%CI[? 1.04, 0.75], P0.01); Comparison of renal function injury and mild renal function injury, compared with mild renal function injury and moderate renal function injury, moderate renal function injury and severe renal function injury, the latter serum NT-proBNP level was higher than the former, and the difference was statistically significant (SMD=? 0.52,95%CI[? 0.19], P0.01; SMD=? 0.84,95%CI[? 1.15, 0.52], P0.01; SMD=? 0.95,95%CI[? 1.43,? 0.47], P0.01) conclusion: severe injury in renal function affects the level of NT-proBNP in the circulation. The level of serum NT-proBNP in patients with heart failure is significantly higher in the case of renal function injury, and it is positively related to the degree of renal function injury; the truncated value of NT-proBNP in the diagnosis of heart failure should be applied in the case of renal function injury. The accuracy of NT-proBNP in the diagnosis of heart failure lies in its high negative predictive value. The defined value of truncation can effectively eliminate heart failure, improve the diagnostic rate and reduce missed diagnosis, and its specificity is poor due to various factors. Significance: the results of this study and conclusion suggest that renal function will affect the NT-proBN in the circulation. The level of P, when combined with renal function and severe injury, significantly increases the level of serum NT-proBNP in patients with heart failure. Therefore, the effect of renal function should be taken into full consideration in the application of N proBNP in the diagnosis of heart failure. A delamination of NT-proBNP for diagnosis of heart failure based on the degree of renal impairment can be more accurately diagnosed. Heart failure combined with renal impairment is of great significance in the diagnosis of clinical heart failure.
【学位授予单位】：青岛大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R541.6

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