Rudenko T E, Vasilyeva M P, Solomakhina N I, Kutyrina I M
I.M. Sechenov First Moscow State Medical University, Ministry of Health of Russia, Moscow, Russia.
Ter Arkh. 2016;88(6):33-39. doi: 10.17116/terarkh201688633-39.
To investigate the incidence and risk factors of pulmonary hypertension (PH) in patients with chronic kidney disease (CKD).
86 patients (53% men, 47% women; mean age, 45±13 years) with nondiabetic CKD were examined. According to the magnitude of glomerular filtration rate (GFR) decrease, all the patients were divided into 3 groups: 1) 33 patients with a GFR of 89--45 ml/min; 2) 33 with a GFR of 44--15 ml/min; 3) 20 with a GFR of <15 ml/min who were treated with hemodialysis. A control group consisted of 20 individuals with preserved kidney function (a GFR of >90 ml/min). Physical examination and transthoracic echocardiography were performed in all the patients. The serum concentrations of N-terminal pro-B-type natriuretic peptide (NT-proBNT) and cystatin C were determined.
PH was detected in 21 (24.4%) of the 86 patients with CKD. As CKD progressed, its prevalence in Groups 1, 2, and 3 increased, amounting to 18.2, 24.2, and 35%, respectively. The most predictably significant risk factors for PH were hypertension (ρ=0.35; р=0.001) and kidney dysfunction (creatinine (ρ=0.23; р=0.02). Elevated pulmonary artery systolic pressure (PASP) correlated with right ventricular (RV) dimension index (ρ=0.45; р<0.0001), right atrial volume index (ρ=0.3; р=0.02), left atrial volume index (ρ=0.3; р=0.009), and left ventricular mass index (ρ=0.35; р=0.03). In all the patients with CKD in the presence of PH, the NT-proBNP level was significantly higher than in its absence: 37.43 (5.83; 59.84) and 8.54 (5.1; 20.43) fmol/ml, respectively (р=0.01). Positive correlations were found between the level of cystatin C and the presence of PH (ρ=0.32; р=0.003). Analysis of the ROC curve (AUC=0.718; р=0.03) in the predialysis-stage CKD groups (n=66) revealed that the cystatin C level of > 1045 ng/ml with a sensitivity of 71% and a specificity of 60% suggested that PH was present. Multivariate analysis showed that the factors correlating with the presence of PH were NT-proBNP (β=0.34; р=0.008) and RV dimension index (β=0.3; р=0.002).
EchoCG reveals PH in almost 25% of the patients with CKD, which occurs at its predialysis stage. Elevated PASP is associated with myocardial structural changes. Traditional risk factors (hypertension) and diminished kidney function affect the development of PH.
研究慢性肾脏病（CKD）患者肺动脉高压（PH）的发病率及危险因素。
对86例非糖尿病CKD患者（男性占53%，女性占47%；平均年龄45±13岁）进行检查。根据肾小球滤过率（GFR）下降幅度，将所有患者分为3组：1）33例GFR为89 - 45 ml/min的患者；2）33例GFR为44 - 15 ml/min的患者；3）20例GFR<15 ml/min且接受血液透析治疗的患者。对照组由20例肾功能正常（GFR>90 ml/min）的个体组成。对所有患者进行体格检查及经胸超声心动图检查。测定血清N末端B型脑钠肽原（NT-proBNT）和胱抑素C浓度。
86例CKD患者中，21例（24.4%）检测出PH。随着CKD病情进展，其在第1、2、3组中的患病率增加，分别为18.2%、24.2%和35%。PH最可预测的显著危险因素为高血压（ρ=0.35；р=0.001）和肾功能不全（肌酐，ρ=0.23；р=0.02）。肺动脉收缩压（PASP）升高与右心室（RV）维度指数（ρ=0.45；р<0.0001）、右心房容积指数（ρ=0.3；р=0.02）、左心房容积指数（ρ=0.3；р=0.009）及左心室质量指数（ρ=0.35；р=0.03）相关。在所有存在PH的CKD患者中，NT-proBNP水平显著高于不存在PH的患者：分别为37.43（5.83；59.84）和8.54（5.1；20.43）fmol/ml（р=0.01）。胱抑素C水平与PH的存在呈正相关（ρ=0.32；р=0.003）。对CKD透析前阶段组（n = 66）的ROC曲线分析（AUC = 0.718；р=0.03）显示，胱抑素C水平>1045 ng/ml，敏感性为71%，特异性为60%，提示存在PH。多因素分析表明，与PH存在相关的因素为NT-proBNP（β=0.34；р=0.008）和RV维度指数（β=0.3；р=0.002）。
超声心动图显示近25%的CKD患者存在PH，且发生于透析前阶段。PASP升高与心肌结构改变相关。传统危险因素（高血压）及肾功能减退影响PH的发生。
