Department of Medicine, Division of Nephrology, Washington DC Veterans Affairs Medical Center, and Department of Anesthesiology and Critical Care Medicine, George Washington University Medical Center, Washington, DC.
Department of Medicine, Division of Cardiology, Hennepin County Medical Center, University of Minnesota, Minneapolis, Minnesota.
J Am Coll Cardiol. 2014 Apr 8;63(13):1246-1252. doi: 10.1016/j.jacc.2014.01.020. Epub 2014 Feb 12.
Structural heart disease is highly prevalent in patients with chronic kidney disease requiring dialysis. More than 80% of patients with end-stage renal disease (ESRD) are reported to have cardiovascular disease. This observation has enormous clinical relevance because the leading causes of death for patients with ESRD are of cardiovascular disease etiology, including heart failure, myocardial infarction, and sudden cardiac death. The 2 systems most commonly used to classify the severity of heart failure are the New York Heart Association (NYHA) functional classification and the American Heart Association (AHA)/American College of Cardiology (ACC) staging system. With rare exceptions, patients with ESRD who do not receive renal replacement therapy (RRT) develop signs and symptoms of heart failure, including dyspnea and edema due to inability of the severely diseased kidneys to excrete sodium and water. Thus, by definition, nearly all patients with ESRD develop a symptomatology consistent with heart failure if fluid removal by RRT is delayed. Neither the AHA/ACC heart failure staging nor the NYHA functional classification system identifies the variable symptomatology that patients with ESRD experience depending upon whether evaluation occurs before or after fluid removal by RRT. Consequently, the incidence, severity, and outcomes of heart failure in patients with ESRD are poorly characterized. The 11th Acute Dialysis Quality Initiative has identified this issue as a critical unmet need for the proper evaluation and treatment of heart failure in patients with ESRD. We propose a classification schema based on patient-reported dyspnea assessed both pre- and post-ultrafiltration, in conjunction with echocardiography.
结构性心脏病在需要透析的慢性肾脏病患者中发病率很高。据报道，超过 80%的终末期肾病 (ESRD) 患者患有心血管疾病。这一观察结果具有巨大的临床意义，因为 ESRD 患者的主要死亡原因是心血管疾病病因，包括心力衰竭、心肌梗死和心源性猝死。用于分类心力衰竭严重程度的两个最常用的系统是纽约心脏协会 (NYHA) 功能分类和美国心脏协会 (AHA)/美国心脏病学会 (ACC) 分期系统。除了罕见的例外，未接受肾脏替代治疗 (RRT) 的 ESRD 患者会出现心力衰竭的体征和症状，包括由于严重疾病的肾脏无法排出钠和水而导致的呼吸困难和水肿。因此，根据定义，如果延迟通过 RRT 去除液体，几乎所有 ESRD 患者都会出现与心力衰竭一致的症状。AHA/ACC 心力衰竭分期和 NYHA 功能分类系统都无法识别 ESRD 患者所经历的不同症状，这取决于在通过 RRT 去除液体前后进行评估。因此，ESRD 患者心力衰竭的发生率、严重程度和结局描述不足。第 11 次急性透析质量倡议已将这一问题确定为 ESRD 患者心力衰竭的正确评估和治疗的一个关键未满足的需求。我们提出了一种基于患者报告的呼吸困难的分类方案，该方案在超滤前后均进行评估，并结合超声心动图进行评估。
