长期动静脉内瘘对非糖尿病肾病血液透析患者心脏结构和功能的影响

摘要

目的 研究长期存在的动静脉内瘘(AVF)对非糖尿病肾病血液透析患者血液动力学以及心脏结构和功能的影响.方法 选择18 ～60岁长期使用AVF作为血管通路的非糖尿病肾病慢性肾衰竭规律血液透析患者50例,采用超声稀释法检测AVF流量(Qa)、搏出量(SV)、心输出量(CO)、心脏指数(CI)、中心血容量(CBV)、外周血管阻力(PR)等血液动力学参数,纽约心脏协会(NYHA)分级标准进行临床心功能评估,于血液透析次日检测超声心动图,分层分析Qa对心脏结构与功能的影响.结果 Qa与SV、CO、CI的关系最佳回归型为三次多项模型,当Qa＞2.0 L/min时,CO明显增加,PR明显降低(P均＜0.05)；Qa 0.6～ 2.0 L/min组与Qa＜ 0.6 L/min组的CO、CI及PR间差异无统计学意义(P均＞0.05).Qa ＞2.0L/min组的心功能明显差于其余两组(P均＜0.05).超声心动图提示,3组间左房直径、室间隔及左室后壁厚度、左室收缩末直径(LVESD)、左室舒张末直径(LVEDD)、下腔静脉、肺动脉收缩压随着Qa的升高而增加,射血分数、左室短轴缩短分数随着Qa的升高而降低,LVESD、LVEDD及下腔静脉直径差异有统计学意义(P均＜0.05).结论 长期AVF可明显影响透析患者心血管系统的血液动力学,三次多项回归曲线为Qa与SV、CO、CI关系的最佳拟合曲线.心脏对AVF的长期适应性改变表现为左室心腔扩大、室壁增厚.当Qa＞2.0 L/min时,PR降低及CO增加更加明显,心力衰竭风险明显增大.%Objective To evaluate the long-term effects of arteriovenous fistula (AVF) on heamody-namic changes and cardiac structure and function in non-diabetic hemodialysis patients. Methods Data were collected from 50 non-diabetic hemodialysis patients (aged 18 to 60 years) who had used AVF as the vascular access. AVF flow ( Qa) , stoke volume (SV) , cardiac output ( CO) , cardiac index (CI) , central blood volume (CBV) and peripheral vascular resistance (PR) were measured using the ultrasound dilution technique. Echocardiography was performed in the second day after hemodialysis sessions to evaluate the influence of AVF on the cardiac structure and function. Results The cubic polynomial regression model best fit the relationships of Qa with SV, CO, and CI. CO and CI significantly increased and PR reduced when the Qa of AVF was more than 2. 0 L/min ( all P < 0. 05) , and no statistical difference of CO, CI and PR in groups of Qa between 0. 6-2. 0 L/min and less than 0. 6 L/min (all P > 0. 05). In different Qa groups, the grades of cardiac function (based on New York Heart Association classification) showed significant difference, among which the cardiac failure was significantly common when Qa > 2. 0 L/min ( both P < 0. 05 ). Echocardiography showed the left atrium dimension, thickness of posterior wall and interventricular seprum of left ventricle, left ventricular end-systolic dimension (LVESD) and end-diastolic dimension (LVEDD) , venae cava inferior, and pulmonary artery systolic pressure gradually increased when Qa increased, while the ejection fraction and fractional shortening reduced ( all P < 0. 05 ). Notably, the changes of LVESD , LVEDD , and venae cava inferior with different Qa were statistically significant (all P< 0.05). Conclusions Long-term AVF remarkably affects the cardiovascular dynamics of non-diabetic hemodialysis patients. A cubic polynomial regression model best fits the relationship of AVF Qa with SV, CO, and CI. The cardiac adaptic changes after long-term AVF include the enlargement of left ventricle and the thickening of ventricular wall. The risk of cardiac failure significantly increases when the Qa of AVF is more than 2. 0 L/min with much higher CO and lower PR.