3-4期慢性肾脏病患者中医证候分布与左心室肥厚的相关性及对肾脏预后的影响

发布时间：2018-08-31 18:53

【摘要】：目的:了解慢性肾脏病(Chronic kidney disease,CKD)3-4期患者中医证型分布及左心室肥厚(left ventricular hypertrophy,LVH)的发生情况,分析二者相关性,并探讨其对CKD3-4期患者肾脏预后的影响。方法:对2012年2月1日至2016年2月1日在湖北省中医院肾病内科门诊随访的61例CKD3-4期患者的基本情况(包括性别、年龄、血压、体质量指数[Body mass index,BMI]等)、肾功能、心脏彩超及中医证型进行基线访视记录,了解CKD3-4期患者中医证型分布及LVH的发生情况,并进行规律随访,记录终点事件(包括血肌酐(Serum creatinine,Scr)水平翻倍、估算的肾小球滤过率(Estimated glomerular filtrationrate,e GFR)15ml/min/1.73m~2或下降大于50%、行肾脏替代治疗及死亡),研究截止时仍未出现终点事件者列为截尾数据。将进入终点事件定义为肾功能进展组,截尾事件定义为肾功能平稳组,比较两组基本情况、中医证候、心脏彩超相关指标等,运用COX风险回归模型对影响肾脏预后的相关因素进行分析。结果:1、61例患者中CKD3期42例,CKD4期19例;平均随访时间(34.70±9.54)个月,其中1例患者脱落,22例患者进入终点,包括12例Scr水平翻倍/e GFR下降大于50%或15 ml/min/1.73m~2、8例进入持续性血液透析治疗、2例死亡(1例脑出血死亡、1例腹主动脉瘤破裂死亡)。2、61例CKD3-4期患者本虚证中脾肾气虚证、脾肾阳虚证、气阴两虚证分别有31例(50.82%)、19例(31.15%)、11例(18.03%),以脾肾气虚证最常见;标实证中湿浊证、湿热证、瘀血证分别有25例(40.98%)、15例(24.59%)、21例(34.43%),以湿浊证最常见。3、61例CKD3-4期患者左心室扩大、LVH、左心室舒张功能减退的比例分别为22.95%、37.70%、60.66%。其中CKD3期左心室扩大、LVH、左心室舒张功能减退的比例分别为23.81%、30.95%、61.90%;CKD4期左心室扩大、LVH、左心室舒张功能减退的比例分别为21.05%、52.63%、57.89%。4、LVH组本虚证中脾肾气虚证、脾肾阳虚证、气阴两虚证分别有5例(21.74%)、9例(39.13%)、9例(39.13%),以脾肾阳虚证及气阴两虚证常见;标实证中湿浊证、湿热证、瘀血证分别有8例(34.78%)、6例(26.09%)、9例(39.13%),以瘀血证最多见;LVH组与非肥厚组在中医本虚证比较中差异有统计学意义(χ~2=16.013,P0.05)。5、LVH组有15例(65.22%)患者进入终点,非肥厚组有7例患者(18.42%)进入终点,两组间差异有统计学意义(χ~2=13.607,P0.05)。6、肾功能进展组本虚证中脾肾气虚证、脾肾阳虚证、气阴两虚证分别有6例(27.27%)、9例(40.91%)、7例(31.82%),以脾肾阳虚证最多见;标实证中湿浊证、湿热证、瘀血证分别有7例(31.82%)、6例(27.27%)、9例(40.91%),以瘀血证最多见。7、肾功能进展组与肾功能平稳组比较,在收缩压、血肌酐、eGFR、室间隔厚度、左室舒张末期内径、左室射血分数、左心室质量(LVM)、左心室质量指数(LVMI)、左心室扩大比例、LVH比例及中医本虚证方面差异有统计学意义(P0.05)。8、COX回归分析单因素分析:收缩压(P=0.013)、LVM(P=0.003)、LVMI(P=0.001)、LVH(P0.001)、左心室扩大(P=0.009)、中医本虚证(P=0.015)为影响CKD3-4期患者肾脏进展的影响因素。多因素分析:收缩压(b=1.075,HR=2.931,P=0.025)、LVH(b=1.319,HR=3.740,P=0.048)、中医本虚证(b=-1.604,HR=0.201,P=0.030)进入回归方程。即收缩压升高是CKD3-4期患者发生终点事件的危险因素,收缩压≥140mmHg进入终点事件的风险是收缩压140mmHg的2.931倍;LVH是CKD3-4期患者发生终点事件的危险因素,LVH患者进入终点事件的风险是无LVH患者的3.740倍;脾肾气虚证是CKD3-4期患者进入终点事件的保护因素,且脾肾气虚证的患者进入终点事件的风险性比脾肾阳虚证患者进入终点的风险性降低79.9%。结论:1、CKD3-4期患者中医证型本虚证以脾肾气虚证最常见,标实证以湿浊证最常见;随着肾功能下降,本虚证中脾肾阳虚证及气阴两虚证患者比例逐渐增多,标实证中瘀血证比例逐渐增多,湿浊证及瘀血证是CKD3-4期患者最主要的邪实之证。2、CKD3-4期患者中LVH已普遍存在,且随着肾功能下降,LVH患者逐渐增多。中医本虚证中脾肾阳虚证及气阴两虚证在LVH形成中可能起一定作用。3、左心室扩大对CKD3-4期患者肾功能进展有一定影响;收缩压升高、LVH是CKD3-4期患者进入终点事件的独立危险因素;早期关注患者心脏彩超情况,及时对血压及左心室结构异常的干预和控制十分必要。4、中医本虚证对CKD3-4期患者肾脏进展影响作用明显,且脾肾阳虚证患者进入终点的相对危险度较脾肾气虚证高,应重视CKD患者脾肾亏虚、本虚标实病理基础。
[Abstract]:Objective: To investigate the distribution of TCM syndromes and the occurrence of left ventricular hypertrophy (LVH) in patients with chronic kidney disease (CKD) stage 3-4, and to analyze the correlation between them, and to explore the influence of LVH on the prognosis of kidney in patients with CKD stage 3-4. Sixty-one patients with CKD 3-4 were followed up in the outpatient department of internal medicine. The basic information (including sex, age, blood pressure, body mass index, BMI), renal function, color Doppler echocardiography and TCM syndrome types were recorded at baseline. The distribution of TCM syndrome types and the occurrence of LVH in the patients with CKD 3-4 were investigated and the end-point events (including blood) were recorded. Serum creatinine (Scr) levels doubled, estimated glomerular filtration rate (e GFR) 15ml/min/1.73m~2 or decreased by more than 50%, for renal replacement therapy and death, and those who did not have an end point at the end of the study were listed as truncated data. Results: Among the 1,61 patients, 42 were CKD 3, 19 were CKD 4, and the average follow-up time was (34.70 9.54) months, including 1 case of shedding and 22 cases of advancing. At the end of the study, including 12 cases of Scr doubled/e GFR decreased more than 50% or 15 ml/min/1.73 m~2, 8 cases of continuous hemodialysis, 2 cases of death (1 case died of cerebral hemorrhage, 1 case died of rupture of abdominal aortic aneurysm). 2, 61 cases of CKD 3-4 patients with deficiency of spleen and kidney qi, spleen and kidney yang, 19 cases of deficiency of Qi and yin, respectively 31 cases (50.82%), 19 cases (31.15%), 1. One case (18.03%) was the spleen and kidney qi deficiency syndrome, 25 cases (40.98%), 15 cases (24.59%) and 21 cases (34.43%) were damp turbidity syndrome, damp-heat syndrome and blood stasis syndrome respectively, and the most common was damp turbidity syndrome. The proportion of ventricular diastolic dysfunction was 23.81%, 30.95% and 61.90% respectively; the proportion of left ventricular enlargement, LVH and left ventricular diastolic dysfunction in CKD4 stage was 21.05%, 52.63% and 57.89% respectively. There were 8 cases (34.78%), 6 cases (26.09%) and 9 cases (39.13%) of dampness-turbidity syndrome, dampness-heat syndrome and blood stasis syndrome, respectively, and the most common was blood stasis syndrome. At the end point, the difference between the two groups was statistically significant (_~2=13.607, P 0.05). There were 6 cases (27.27%), 9 cases (40.91%) and 7 cases (31.82%) of spleen and kidney yang deficiency, 6 cases (27.27%) of spleen and kidney yang deficiency, 9 cases (40.91%) of spleen and kidney yang deficiency, and 7 cases (31.82%) of dampness and heat, and blood stasis, respectively. There were significant differences in systolic blood pressure, serum creatinine, eGFR, interventricular septal thickness, left ventricular end-diastolic diameter, left ventricular ejection fraction, left ventricular mass (LVM), left ventricular mass index (LVMI), left ventricular enlargement ratio, LVH ratio and deficiency syndrome of traditional Chinese medicine (P 0.0). 5).8, COX regression analysis of univariate analysis: systolic pressure (P = 0.013), LVM (P = 0.003), LVM (P = 0.003), LVMI (P = 0.001), LVH (P = 0.001), left ventricular enlarge (P = 0.009), and deficiency syndrome of traditional Chinese medicine (P = 0.015) were the influenfactors of CKD3-4 patients with kidnprogression. Multivariatanalysis: systostolic pressure (b = 1.075, HR = 2.931, P = 0.931, P = 0.025), LVH (b = 1.31749, HR = 1.31749, HR = 3.749, HR = 3.749, 3.3.749, 3.Syndrome (b = - 1.6) 04, HR = 0.201, P = 0.030) entered the regression equation, i.e. elevated systolic blood pressure was a risk factor for end-point events in patients with CKD 3-4. The risk of end-point events with systolic blood pressure (> 140 mmHg) was 2.931 times higher than that with systolic blood pressure (> 140 mmHg); LVH was a risk factor for end-point events in patients with CKD 3-4; and the risk of end-point events in patients with LVH was 3.74 times higher than that in patients without L Spleen-kidney Qi deficiency syndrome is the protective factor of CKD 3-4 patients entering the end-point events, and the risk of spleen-kidney Qi deficiency patients entering the end-point events is 79.9% lower than that of spleen-kidney Yang deficiency patients entering the end-point events. The proportion of patients with deficiency of spleen and kidney yang and deficiency of both qi and Yin in this deficiency syndrome increased gradually, and the proportion of blood stasis syndrome increased gradually. Damp turbidity syndrome and blood stasis syndrome were the most important pathogenic syndrome in CKD 3-4. 2. LVH was prevalent in CKD 3-4 patients, and with the decline of renal function, the number of LVH patients increased gradually. Kidney-yang deficiency syndrome and Qi-yin deficiency syndrome may play a role in the formation of LVH. 3. Left ventricular enlargement has a certain impact on the progress of renal function in patients with CKD3-4; elevated systolic blood pressure, LVH is an independent risk factor for CKD3-4 patients entering the end point; early attention to patients with heart color Doppler ultrasound, timely intervention and left ventricular structural abnormalities of blood pressure and left ventricular dysfunction It is necessary to control the disease. 4. The deficiency of spleen and kidney in TCM has an obvious effect on the progress of kidney in patients with CKD stage 3-4, and the relative risk of spleen and kidney yang deficiency is higher than that of spleen and kidney qi deficiency.
【学位授予单位】：湖北中医药大学
【学位级别】：硕士
【学位授予年份】：2016
【分类号】：R277.5

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