缺血性脑卒中患者急性期血尿酸水平及与短期预后的相关性

发布时间：2018-05-27 17:24

本文选题：血清尿酸 + 高尿酸血症　；参考：《河北医科大学》2014年硕士论文

【摘要】：目的：尿酸（uric acid，UA）是人体内源性和外源性嘌呤在黄嘌呤氧化酶作用下的代谢终产物，作为机体内代谢紊乱的标志物与多种脑血管病危险因素密切相关。在正常情况下，人体内每天尿酸的产生和排泄基本上保持动态平衡。当机体嘌呤生成过多或肾脏尿酸排出减少时即可导致高尿酸血症（hyeruricemia，HUA）。HUA与代谢综合征（metabolic syndrome，MS）的许多组分如高血压、高血糖、脂代谢紊乱、冠心病、肥胖及胰岛素抵抗等密切相关，并且通过多种作用机制导致动脉粥样硬化的发生与发展。大量研究表明，高尿酸血症作为新的脑血管病危险因素可能与缺血性脑卒中的发生风险增加、不良预后及早期死亡有关。同时，，也有研究认为：UA作为有效的抗氧化剂和自由基清除剂，对急性缺血性脑卒中具有神经保护作用，可以改善卒中预后、减少卒中复发。但目前血尿酸对缺血性脑卒中的作用仍然存在争议，基于此，本研究通过大样本、回顾性分析，观察缺血性脑卒中急性期血尿酸水平，评价其与卒中短期预后的相关关系。方法:采用回顾性研究，以2009年3月～2013年9月收住河北医科大学第三医院神经内科的急性脑梗死患者作为研究对象，入组患者为依据经典TOAST病因分型明确诊断为大动脉粥样硬化型（large-arteryatherosclerosis，LAA）及小动脉闭塞型脑梗死型（small-artery occlusion，SAO）患者，共1085例。所有入组患者均具有详细的临床资料包括：人口构成情况、血管病危险因素病史及家族史、头颅结构影像学及血管影像学如经颅多普勒超声、颈动脉彩超、血液学检查结果及基线状态神经功能缺损程度及病情转归情况记录等。排除如下患者：（1）临床资料不全，难以进行TOAST病因分型者、缺乏血清尿酸检测结果者，以及心源性栓塞、其他病因、未明原因的卒中患者；（2）因既往疾病所遗留后遗症而难以评估病情者；（3）痛风患者；（4）患有心、肝、肾等严重功能不全（慢性肾炎、高血压性肾病、糖尿病性肾病）者；（5）患有精神疾病者；（6）高血压危象、高血压脑病者；（7）应用噻嗪类利尿剂者。所有患者均于发病后7天内入院，平均住院时间为14天。对于原始病例中无NIHSS评分记录的患者，依据入院、出院时临床查体所见进行评分。短期不良预后的判断标准包括：(1）住院期间死亡；(2）依据美国国立卫生研究院脑卒中量表（National Institute of Health Stroke Scale，NIHSS）标准评分，出院时NIHSS评分与入院基线状态NIHSS评分下降的百分比作为指标，即（入院时NIHSS评分-出院时NIHSS评分）/入院时NIHSS评分40%判断为预后不良。采用SPSS16.0软件进行统计学分析。计数资料以阳性例数、构成比表示，采用χ2检验。计量资料采用均数±标准差形式表示，采用t检验。多因素分析采用Logistic回归分析。P 0.05判定为差异有统计学意义。比较不同类型卒中患者高尿酸血症发病率；将入组患者人口构成情况及TOAST分型、高血压病、糖尿病、高脂血症、冠心病、心脑血管病家族史、血尿酸、血尿素、血肌酐和血红蛋白水平作为自变量，将单因素分析有统计学意义的指标再进一步通过多因素相关分析，评价急性脑梗死患者HUA的独立危险因素及与卒中短期预后的相关性。结果：1、1085例患者满足入组标准纳入本研究。其中，男性709例（65.35%），女性376例（36.45%）；LAA、SAO患者分别为747例(68.85%)、338例(31.15%)；依据出院与基线状态NIHSS评分下降百分比，预后不良患者共346例（31.89%），其中住院期间死亡10例，预后良好患者共739例（61.11%）。所有被研究患者高尿酸血症（hyeruricemia，HUA）的发病率11.15%，LAA组患者高尿酸血症的发病率14.46%，显著高于SAO组患者3.85%（χ2=22.866，OR=4.225，P=0.000）；低血尿酸水平患者占1.29%，血尿酸水平异常的总发病率12.44%。预后不良患者中14.74%伴发HUA，低血尿酸水平患者占2.02%，尿酸水平异常的总发病率为16.76%。2、以HUA为因变量，分别以高血压病、糖尿病、高脂血症等脑血管病危险因素为自变量，通过单因素Logistic回归分析发现:高血压病、高脂血症、高尿素血症、高肌酐血症是HUA发生的危险因素。而性别、年龄、吸烟、饮酒、糖尿病、心脏病、心脑血管病家族史、低血红蛋白与HUA发生无显著相关性。在调整了年龄、性别等因素后，进一步经多因素Logistic回归分析显示：高肌酐血症（OR=5.767,95%CI:3.101～10.723, P=0.000）、LAA（OR=4.332,95%CI:2.356～7.966,P=0.000）、高尿素血症（OR=2.307,95%CI:1.283～4.148, P=0.005）、高脂血症（OR=2.017,95%CI:1.307～3.112, P=0.002)增加HUA的发病风险，为HUA的独立危险因素。3、以卒中患者短期出院时神经功能缺损程度作为因变量，评价急性缺血性脑卒中短期预后不良的危险因素。以高血压病、糖尿病、高脂血症等脑血管病危险因素为自变量，通过单因素分析发现：HUA（χ2=6.502，OR=1.652，P=0.011）、尿酸水平异常（χ2=8.558，OR=1.731，P=0.003）、高血压病、糖尿病、高尿素血症增加急性缺血性脑卒中患者短期预后不良的发生危险。而性别、年龄、LAA、吸烟、高脂血症、心脏病、心脑血管病家族史、高肌酐血症、低血红蛋白与患者短期预后无显著相关性。通过多因素Logistic回归分析显示：HUA（OR=1.448，95%CI:0.967～2.168, P=0.072）与急性缺血性脑卒中患者短期预后不良无相关性，而高尿素血症（OR=1.748,95%CI:1.107～2.760, P=0.017）、高血压病(OR=1.635,95%CI:1.183～2.260, P=0.003)、尿酸水平异常(OR=1.515,95%CI:1.031～2.225, P=0.034)、糖尿病（OR=1.362,95%CI:1.037～1.790,P=0.026）为急性缺血性脑卒中患者短期预后不良的独立危险因素。结论： LAA型脑梗死、高脂血症患者更易伴发HUA，尿酸水平异常为卒中患者短期预后不良的独立危险因素，但HUA对急性缺血性脑卒中的短期不良预后无预测价值。
[Abstract]:Objective: uric acid (UA) is a metabolic end product of endogenous and exogenous purines under the action of xanthine oxidase. As a marker of metabolic disorders in the body, it is closely related to the risk factors of various cerebrovascular diseases. In normal cases, the production and excretion of uric acid in the human body is basically balanced. High uricemia (hyeruricemia, HUA).HUA and metabolic syndrome (metabolic syndrome, MS) can lead to many components of hyperuricemia (metabolic syndrome, MS), such as hypertension, hyperglycemia, lipid metabolism disorder, coronary heart disease, obesity and insulin resistance, and lead to atherosclerosis through a variety of mechanisms of action. Birth and development. A large number of studies have shown that hyperuricemia as a new risk factor for cerebrovascular disease may be associated with increased risk of ischemic stroke, poor prognosis and early death. At the same time, UA is considered as an effective antioxidant and free radical scavenger, which has neuroprotective effect on acute ischemic stroke. It can improve the prognosis of stroke and reduce the recurrence of stroke. However, the current effect of blood uric acid on ischemic stroke is still controversial. Based on this, this study, through a large sample, retrospective analysis, observed the level of uric acid in the acute phase of ischemic stroke, and evaluated the correlation with the short-term prognosis of stroke.
Methods: a retrospective study was conducted to study the acute cerebral infarction patients in the neurology department of the Third Hospital of Hebei Medical University from March 2009 to September 2013. The patients were diagnosed as large-arteryatherosclerosis (LAA) and cerebral infarction type of small artery occlusion (s) according to the classic TOAST etiological type (s Mall-artery occlusion, SAO) patients, with a total of 1085 cases. All the patients had detailed clinical data including population composition, history of risk factors for vascular diseases, family history, cranial structure imaging, and vascular imaging such as transcranial Doppler ultrasound, carotid color Doppler ultrasound, hematological examination results and baseline state neural function defect process. The following patients were excluded: (1) poor clinical data, difficult to carry out TOAST etiological types, lack of serum uric acid test results, cardiac embolism, other causes, unknown causes of stroke patients; (2) (3) gout patients; (4) suffering from the sequelae of previous diseases; (3) Heart, liver, kidney and other severe dysfunction (chronic nephritis, hypertensive nephropathy, diabetic nephropathy); (5) patients with mental illness; (6) hypertensive crisis, hypertensive encephalopathy; (7) use thiazine diuretics. All patients were admitted to hospital within 7 days after the onset of the disease, the average length of hospitalization was 14 days. No NIHSS score was recorded in the original cases. The patients were assessed on the basis of admission and clinical findings at discharge. The criteria for short-term poor prognosis included: (1) death during hospitalization; (2) according to the National Institutes of Health Stroke Scale (National Institute of Health Stroke Scale, NIHSS) standard score, NIHSS score at discharge and admission baseline state NIHSS score The percentage of fall as an indicator, i.e., NIHSS score at admission (NIHSS score at discharge) / NIHSS score at admission, was 40%.
Statistical analysis was carried out by SPSS16.0 software. The count data were expressed as positive cases and composition ratio, using chi 2 test. The measurement data were represented by mean number of standard deviation and t test. The multiple factor analysis using Logistic regression analysis.P 0.05 was statistically significant. Compared with the incidence of hyperuricemia in different types of stroke patients Rate; the population composition of the patients and TOAST classification, hypertension, diabetes, hyperlipidemia, coronary heart disease, family history of cardio cerebral vascular disease, blood uric acid, blood urea, blood creatinine and hemoglobin levels were used as independent variables, and the statistical indexes of single factor analysis were further analyzed by multi factor correlation analysis to evaluate acute cerebral infarction. Independent risk factors of HUA and its correlation with short-term prognosis in stroke patients.
Results: 11085 patients met the criteria for admission to the study. Among them, 709 (65.35%) and 376 (36.45%) women were male; LAA, SAO patients were 747 (68.85%) and 338 (31.15%); 346 patients (31.89%) had poor prognosis based on the discharge and baseline NIHSS scores. Among them, there were 10 cases of death during hospitalization, and the prognosis was good. There were 739 cases (61.11%). The incidence of hyperuricemia (hyeruricemia, HUA) in all the patients was 11.15%, and the incidence of hyperuricemia in group LAA was 14.46%, significantly higher than that in group SAO (x 2=22.866, OR=4.225, P=0.000), low uric acid level in 1.29%, and the total incidence of abnormal serum uric acid in 12.44%., 1 in poor prognosis patients. 4.74% with HUA, low blood uric acid level in 2.02%, the total incidence of abnormal uric acid level was 16.76%.2, HUA as the dependent variable, hypertension, diabetes, hyperlipidemia and other risk factors of cerebrovascular disease as independent variables, through single factor Logistic regression analysis found: hypertension, hyperlipidemia, high urea, hypercreatinine is H There was no significant correlation between sex, age, smoking, smoking, drinking, diabetes, heart disease, family history of cardiovascular and cerebrovascular diseases, and there was no significant correlation between the incidence of low hemoglobin and HUA. After adjusting the age, sex and other factors, the multiple factor Logistic regression analysis showed that hypercreatinine (OR=5.767,95%CI:3.101 to 10.723, P=0.000), LAA (OR=4.) 332,95%CI:2.356 ~ 7.966, P=0.000), hyperurea (OR=2.307,95%CI:1.283 ~ 4.148, P=0.005), hyperlipidemia (OR=2.017,95%CI:1.307 to 3.112, P=0.002) increased the risk of HUA, an independent risk factor for HUA, which was a dependent variable in the short-term discharge of stroke patients, to evaluate the short stroke of acute ischemic stroke. The risk factors of poor prognosis. The risk factors of cerebrovascular disease such as hypertension, diabetes and hyperlipidemia are independent variables. Through single factor analysis, it is found that HUA (x 2=6.502, OR=1.652, P=0.011), abnormal uric acid level (x 2=8.558, OR=1.731, P=0.003), hypertension, diabetes, and high urea increase the short term of acute ischemic stroke There was no significant correlation between sex, age, LAA, smoking, hyperlipidemia, heart disease, family history of cardio cerebrovascular disease, hypercreatinine, and low hemoglobin, and short term prognosis. Multiple factor Logistic regression analysis showed that HUA (OR=1.448,95%CI:0.967 ~ 2.168, P=0.072) and acute ischemic stroke patients were short Poor prognosis was not associated with high urea (OR=1.748,95%CI:1.107 ~ 2.760, P=0.017), hypertension (OR=1.635,95%CI:1.183 to 2.260, P=0.003), abnormal uric acid (OR=1.515,95%CI:1.031 to 2.225, P=0.034), diabetes (OR=1.362,95%CI:1.037 to 1.790, P=0.026) for the short-term prognosis of acute ischemic stroke patients. Independent risk factors.
Conclusion:
Patients with type LAA cerebral infarction and hyperlipidemia are more likely to be associated with HUA. The abnormal level of uric acid is an independent risk factor for the short term prognosis of stroke patients, but HUA has no predictive value for the short-term prognosis of acute ischemic stroke.
【学位授予单位】：河北医科大学
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：R743.3

【引证文献】