在无晚期冠状动脉疾病的血液透析患者中检测冠状动脉疾病的最佳二次筛查点。

Optimum second screening point for detection of coronary artery disease in hemodialysis patients without advanced coronary artery disease.

作者信息

Joki Nobuhiko, Tanaka Yuri, Ishikawa Hiroyasu, Takahashi Yasunori, Iwakura Yoshitsugu, Masuda Haruka, Inishi Yoji, Hase Hiroki

机构信息

Department of Nephrology, Toho University Ohashi Medical Center, 2-17-6 Ohashi, Meguro-ku, Tokyo, Japan.

出版信息

Am J Nephrol. 2009;29(5):420-5. doi: 10.1159/000172617. Epub 2008 Nov 7.

DOI:10.1159/000172617

PMID:18997458

Abstract

BACKGROUND

Screening for coronary artery disease (CAD) at the initiation of dialysis is a K/DOQI recommendation. However, it remains unclear when screening for CAD should be repeated in patients without significant disease at the time of starting dialysis. The objectives of this study were to determine: (1) the survival of hemodialysis (HD) patients without CAD at the initiation of dialysis, (2) the major predictors of CAD events, and (3) the best time to repeat screening for CAD after the initiation of HD.

METHODS

In order to assess the occurrence of de novo major adverse cardiac events (MACE) in HD patients without CAD, we prospectively followed patients who were normal according to screening tests for CAD performed at the initiation of HD. To detect CAD, 177 of 305 new HD patients underwent coronary angiography and/or pharmacologic stress thallium-201 single photon emission computed tomography within 1 month after starting HD. Among these 177 patients, 100 did not have significant CAD and they were followed for a median of 24 months.

RESULTS

Five MACE occurred during follow-up, but no events were observed within 1 year after starting HD. All 5 events occurred during the second year of HD (two events occurred immediately after the end of the first year). An increased level of C-reactive protein (CRP) was the only independent predictor of MACE (hazard ratio: 1.39; 95% CI: 1.03-1.78, p = 0.008) according to Cox regression analysis. The optimum cut-off value of CRP for predicting MACE was 3.5 mg/l. The MACE-free rate at 2 years (99 vs. 79%, p = 0.0008) was significantly higher in patients with a CRP level (3.5 mg/l than in those with a level <3.5 mg/l).

CONCLUSION

One year after the initiation of HD could be the optimum time to repeat screening for CAD in patients without disease at the initiation of HD. If the serum CRP level is less than 3.5 mg/l, postponing repeat screening for CAD could be considered.

摘要

背景

在开始透析时筛查冠状动脉疾病（CAD）是肾脏疾病改善全球预后（K/DOQI）的一项建议。然而，对于开始透析时无明显疾病的患者，尚不清楚何时应再次进行CAD筛查。本研究的目的是确定：（1）透析开始时无CAD的血液透析（HD）患者的生存率，（2）CAD事件的主要预测因素，以及（3）HD开始后再次筛查CAD的最佳时间。

方法

为了评估无CAD的HD患者发生新发主要不良心脏事件（MACE）的情况，我们对HD开始时CAD筛查试验结果正常的患者进行了前瞻性随访。为了检测CAD，305例新的HD患者中有177例在开始HD后1个月内接受了冠状动脉造影和/或药物负荷铊-201单光子发射计算机断层扫描。在这177例患者中，100例没有明显的CAD，对他们进行了为期24个月的中位随访。

结果

随访期间发生了5例MACE，但在开始HD后的1年内未观察到事件。所有5例事件均发生在HD的第二年（2例事件在第一年结束后立即发生）。根据Cox回归分析，C反应蛋白（CRP）水平升高是MACE的唯一独立预测因素（风险比：1.39；95%可信区间：1.03-1.78，p = 0.008）。预测MACE的CRP最佳临界值为3.5mg/l。CRP水平<3.5mg/l的患者2年无MACE率（99%对79%，p = 0.0008）显著高于CRP水平≥3.5mg/l的患者。