肾功能不全患者心脏再同步治疗的反应及结果
Response and outcomes of cardiac resynchronization therapy in patients with renal dysfunction.
作者信息
Moreira Rita Ilhão, Cunha Pedro Silva, Rio Pedro, da Silva Manuel Nogueira, Branco Luísa Moura, Galrinho Ana, Feliciano Joana, Soares Rui, Ferreira Rui Cruz, Oliveira Mário Martins
机构信息
Department of Cardiology, Hospital de Santa Marta, Centro Hospitalar Lisboa Central, Rua de Santa Marta, n° 50, 1169-024, Lisbon, Portugal.
出版信息
J Interv Card Electrophysiol. 2018 Apr;51(3):237-244. doi: 10.1007/s10840-018-0330-6. Epub 2018 Feb 19.
PURPOSE
Renal dysfunction is often associated with chronic heart failure, leading to increased morbi-mortality. However, data regarding these patients after cardiac resynchronization therapy (CRT) is sparse. We sought to evaluate response and long-term mortality in patients with heart failure and renal dysfunction and assess renal improvement after CRT.
METHODS
We analyzed 178 consecutive patients who underwent successful CRT device implantation (age 64 ± 11 years; 69% male; 92% in New York Heart Association (NYHA) functional class ≥ III; 34% with ischemic cardiomyopathy). Echocardiographic response was defined as ≥ 15% reduction in left ventricular end-systolic diameter and clinical response as a sustained improvement of at least one NYHA functional class. Renal dysfunction was defined as an estimated glomerular filtration rate (eGFR) below 60 mL/min/1.73 m.
RESULTS
Renal dysfunction was present in 34.7%. Renal dysfunction was not an independent predictor of echocardiographic response (OR 1.109, 95% CI 0.713-1.725, p 0.646) nor clinical response (OR 1.003; 95% CI 0.997-1.010; p 0.324). During follow-up (mean 55.2 ± 32 months), patients with eGFR < 60mL/min/1.73 m had higher overall mortality (HR 4.902, 95% CI 1.118-21.482, p 0.035). However, clinical response in patients with renal dysfunction was independently associated with better long-term survival (HR 0.236, 95% CI 0.073-0.767, p 0.016). Renal function was significantly improved in patients who respond to CRT (ΔeGFR + 5.5 mL/min/1.73 m at baseline vs. follow-up, p 0.049), while this was not evident in nonresponders. Improvements in eGFR of at least 10 mL/min/1.73 m were associated with improved survival in renal dysfunction patients (log-rank p 0.036).
CONCLUSION
Renal dysfunction was associated with higher long-term mortality in CRT patients, though, it did not influence echocardiographic nor functional response. Despite worse overall prognosis, renal dysfunction patients who are responders showed long-term survival benefit and improvement in renal function following CRT.
目的
肾功能不全常与慢性心力衰竭相关，导致病残率和死亡率增加。然而，关于这些患者接受心脏再同步治疗（CRT）后的资料较少。我们试图评估心力衰竭合并肾功能不全患者的反应及长期死亡率，并评估CRT后肾功能的改善情况。
方法
我们分析了178例连续成功植入CRT装置的患者（年龄64±11岁；69%为男性；92%纽约心脏协会（NYHA）心功能分级≥Ⅲ级；34%为缺血性心肌病）。超声心动图反应定义为左心室收缩末期内径减少≥15%，临床反应定义为NYHA心功能分级至少持续改善一级。肾功能不全定义为估算肾小球滤过率（eGFR）低于60 mL/min/1.73 m²。
结果
34.7%的患者存在肾功能不全。肾功能不全不是超声心动图反应（比值比1.109，95%可信区间0.713 - 1.725，p = 0.646）或临床反应（比值比1.003；95%可信区间0.997 - 1.010；p = 0.324）的独立预测因素。在随访期间（平均55.2±32个月），eGFR < 60 mL/min/1.73 m²的患者总体死亡率较高（风险比4.902，95%可信区间1.118 - 21.482，p = 0.035）。然而，肾功能不全患者的临床反应与更好的长期生存独立相关（风险比0.236，95%可信区间0.073 - 0.767，p = 0.016）。对CRT有反应的患者肾功能显著改善（基线时eGFR与随访时相比增加5.5 mL/min/1.73 m²，p = 0.049），而无反应者则不明显。eGFR至少改善10 mL/min/1.73 m²与肾功能不全患者生存率提高相关（对数秩检验p = 0.036）。
结论
肾功能不全与CRT患者较高的长期死亡率相关，尽管它不影响超声心动图反应或功能反应。尽管总体预后较差，但对CRT有反应的肾功能不全患者显示出长期生存获益且CRT后肾功能有所改善。
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