肾功能不全对心脏再同步治疗心力衰竭患者长期临床结局的影响。
Impact of renal insufficiency on long-term clinical outcome in patients with heart failure treated by cardiac resynchronization therapy.
机构信息
Department of Cardiology, Yokohama City University Hospital, Yokohama, Japan.
出版信息
J Cardiol. 2012 Oct;60(4):301-5. doi: 10.1016/j.jjcc.2012.06.001. Epub 2012 Jul 2.
BACKGROUND
Renal insufficiency is recognized as a predictor of mortality and adverse outcome in heart failure (HF) patients. However, the long-term clinical outcome of cardiac resynchronization therapy (CRT) in Japanese HF patients with renal insufficiency remains uncertain.
METHODS
We evaluated 67 consecutive patients who underwent CRT at our hospital. The patients were divided into two groups according to a baseline estimated glomerular filtration rate (e-GFR) cut-off value of 50ml/min, which is defined as the time at which patients should be referred to a nephrologist, by the Japanese Society of Nephrology. Follow-up echocardiographic findings and renal function were examined at 3-6 months after CRT. Then, we compared long-term clinical outcomes between the two groups, and analyzed the effect of CRT on renal function, echocardiographic parameters and cardiac survival.
RESULTS
During a mean follow-up period of 30.3 months, patients with advanced renal insufficiency (e-GFR<50ml/min) had significant higher all-cause mortality (log-rank p=0.033) and higher cardiac mortality combined with HF hospitalization (log-rank p=0.017) than patients with e-GFR≥50ml/min. Multivariate analysis revealed that advanced renal insufficiency was an independent predictor of cardiac mortality combined with HF hospitalization (odds ratio=3.01, p=0.008). Subgroup analysis in the baseline advanced renal insufficiency group revealed that patients with preserved renal function by CRT (<10% reduction in e-GFR) had a higher rate of decrease of left ventricular end-systolic diameter (-14.0% vs. -0.8%, p=0.023) and lower cardiac mortality combined with HF hospitalization (log-rank p=0.029) compared with patients with deterioration of renal function (≥10% reduction in e-GFR).
CONCLUSIONS
The present study suggests that advanced renal insufficiency is quite useful for the prediction of worsening clinical outcomes in HF patients treated by CRT. Preservation of renal function by CRT brings about better cardiac survival through prevention of adverse cardiac events, even in HF patients with advanced renal insufficiency.
背景
肾功能不全被认为是心力衰竭（HF）患者死亡率和不良预后的预测指标。然而，肾功能不全的日本 HF 患者接受心脏再同步治疗（CRT）的长期临床结局仍不确定。
方法
我们评估了在我院接受 CRT 的 67 例连续患者。根据日本肾脏病学会定义的肾小球滤过率（e-GFR）基线截止值 50ml/min，将患者分为两组。在 CRT 后 3-6 个月检查随访超声心动图发现和肾功能。然后，我们比较了两组之间的长期临床结局，并分析了 CRT 对肾功能、超声心动图参数和心脏生存率的影响。
结果
在平均 30.3 个月的随访期间，肾功能不全较严重的患者（e-GFR<50ml/min）的全因死亡率（log-rank p=0.033）和心脏死亡率合并 HF 住院率（log-rank p=0.017）均显著较高。多变量分析显示，肾功能不全是心脏死亡率合并 HF 住院率的独立预测因素（优势比=3.01，p=0.008）。在基线肾功能不全较严重组的亚组分析中，CRT 后肾功能保留的患者（e-GFR 降低<10%）的左心室收缩末期直径下降率较高（-14.0%vs.-0.8%，p=0.023），心脏死亡率合并 HF 住院率较低（log-rank p=0.029），与肾功能恶化的患者（e-GFR 降低≥10%）相比。
结论
本研究表明，肾功能不全对 CRT 治疗的 HF 患者预后恶化的预测具有重要意义。CRT 可保留肾功能，通过预防不良心脏事件带来更好的心脏生存率，即使在肾功能不全较严重的 HF 患者中也是如此。
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