冠状动脉粥样硬化性心脏病合并慢性肾功能不全患者临床特征和经皮冠状动脉介入围术期急性肾损伤发生情况及远期预后评估

摘要

目的 探讨冠状动脉粥样硬化性心脏病(冠心病)合并慢性肾脏病(CKD)的临床特征,患者经皮冠状动脉介入(PCI)围术期急性肾损伤(AKI)的发生情况,术后远期预后及相关危险因素.方法 回顾性分析2012年1月至2016年12月首都医科大学附属北京安贞医院收治的冠心病行PCI且合并CKD的1 156例患者病历资料.根据入院时基线估算肾小球滤过率(eGFR)将患者分为eGFR≥60～90 ml/(min·1.73 m2)组(698例)、eGFR≥30～ ＜60 ml/(min·1.73 m2)组(356例)、eGFR≥15 ～ ＜30 ml/(min·1.73 m2)组(84例)、eGFR＜ 15 ml/(min·1.73 m2)组(18例).分析患者人口学资料、临床特征、围术期AKI以及随访12个月主要不良心血管事件(MACE)发生情况.结果 冠心病合并CKD患者随着肾功能(eGFR)的降低多伴随高龄(P＜0.001)、高血压(P =0.002)、高脂血症(P＜0.001)等人群特征.总体AKI发生率为8.5％(98/1 156).总体MACE发生率为8.7％ (100/1 156).多因素Logistic回归模型分析提示,基线eGFR(比值比=0.979,P=0.002)、高血压(比值比=7.319,P＜0.001)、左心室射血分数(比值比=0.854,P＜0.001)为围术期AKI的危险因素.Cox回归风险模型分析显示,AKI(风险比=11.955,P＜0.001)、基线eGFR(风险比=0.962,P＜0.001)、年龄(风险比=1.040,P=0.003)、左心室射血分数(风险比=0.958,P＜0.001)是冠心病合并CKD患者MACE的独立危险因素.Kaplan-Meier曲线分析显示,围术期发生AKI的患者预后差,随访MACE发生率高(P＜0.001).结论 冠心病合并CKD患者群具有高血压、高血脂等代谢综合征特点,肾功能差、高血压、左心室射血分数低的人群更易导致AKI发生,PCI围术期发生AKI的患者预后较差.%Objective To investigate the clinical characteristics of patients with coronary atherosclerotic heart disease(CHD) complicated with chronic kidney disease(CKD),the occurrence of perioperative acute renal injury (AKI) after percutaneous coronary intervention (PCI) and the risk factors of long-term prognosis.Methods A total of 1 156 CHD with CKD patients who had PCI in Beijing Anzhen Hospital,Capital Medical University from January 2012 to December 2016 were retrospectively analyzed.According to the baseline level of estimated glomerular filtration rate (eGFR) on admission,the patients were divided into 4 groups:eGFR≥ 60-90ml/(min· 1.73 m2)(n =698),eGFR ≥ 30-＜ 60 ml/(min · 1.73 m2) (n =356),eGFR ≥ 15-＜ 30 ml/(min · 1.73 m2) (n =84),eGFR ＜ 15 mL/(min · 1.73 m2) (n =18).Demographic data,clinical characteristics,perioperative AKI and major adverse cardiovascular events (MACE) in 12 months after PC1 were analyzed.Results CHD patients with severe CKD(low eGFR) were associated with advanced age(P ＜0.001),hypertension(P =0.002) and hyperlipidemia(P ＜ 0.001).Incidence of AKI was 8.5％ (98/1 156).Incidence of MACE was 8.7％ (100/1 156).Multivariate logistic regression showed that baseline eGFR(odds ratio =0.979,P =0.002),hypertension (odds ratio =7.319,P ＜ 0.001) and left ventricular ejection fraction (odds ratio =0.854,P ＜0.001) were risk factors of AKI during perioperative period of PCI.Cox regression risk model showed that AKI(hazard ratio =11.955,P ＜ 0.001),baseline eGFR (hazard ratio =0.962,P ＜ 0.001),age (hazard ratio =1.040,P =0.003) and left ventricular ejection fraction(hazard ratio =0.958,P ＜ 0.001) were independent risk factors of 12-month MACE.Kaplan-Meier curve indicated that patients with perioperative AKI had poor prognosis;incidence of MACE in AKI patients was higher than that in non-AKI patients (P ＜ 0.001).Conclusions CHD patients with CKD have metabolism syndrome components of hypertension and hyperlipemia.Poor renal function,hypertension and low left ventricular ejection fraction may increase the risk of AKI.Patients with perioperative AKI after PCI have poor prognosis.