本文選題：尿毒癥　切入點：超聲　出處：《華中科技大學》2014年博士論文

【摘要】：前言 多種慢性腎臟疾病終末期表現(xiàn)為尿毒癥,其顯著增加并發(fā)心血管疾病和死亡的風險。心血管事件是尿毒癥患者死亡的首要原因,約58%的慢性腎臟疾病患者死于心血管疾病,常見為心源性猝死及心衰。心臟重構為心肌受損或心臟負荷增加所導致心臟大小、形狀及功能改變。左室肥厚是慢性腎臟疾病患者最常見的心血管并發(fā)癥之一,往往預示預后較差。臨床上75%成人尿毒癥患者開始透析時有左室肥厚。尿毒癥時心臟病理學改變包括纖維化、肥厚、心肌組織冠脈灌注減少。 目前尿毒癥的治療方式主要為腎移植和透析。與透析治療相比,腎移植治療能明顯降低死亡率,被認為是終末期慢性腎臟病的標準治療。Dzemidzic等認為,移植后左室質(zhì)量減少與尿毒癥相關危險因素減少有關。評價腎移植術后左室質(zhì)量變化對評估患者預后有重要臨床意義,然而,對于腎移植術后左室質(zhì)量是否減少目前仍存在爭議。早期研究表明腎移植術后心功能明顯改善、左室肥厚減輕。Montanaro等認為腎移植術后左室質(zhì)量減少,而Patel等研究表顯示腎移植術后左室質(zhì)量無明顯變化。近期Vaidya等研究認為,移植后大部分患者左室質(zhì)量減少,仍有少數(shù)患者左室質(zhì)量無明顯變化,并提出左室質(zhì)量減少程度與術前肥厚程度相關。 腎移植較維持性血液透析者有更高的生存率,USRDS數(shù)據(jù)表明,接受腎移植的患者死亡率明顯較接受常規(guī)透析患者低。然而,腎移植患者每年遭受非致死性心血管事件的發(fā)生率是一般人群的50倍,死于心功能不全的發(fā)生率是一般人群的10倍。相關研究指出,移植術后收縮功能不全患者心血管事件死亡率較收縮功能正常腎移植患者增加,因此,評價尿毒癥患者腎移植術后左室收縮功能有重要意義。 臨床上評估左室結構及功能的技術有磁共振成像、放射性核素、心血管造影、CT、心導管及超聲心動圖等。磁共振成像被認為是評價左室結構及功能的金標準,但是其檢查費用昂貴、檢查時間長,有一定的禁忌癥,限制了其在臨床上廣泛應用；放射性核素、心血管造影、心導管檢查具有侵襲性；CT檢查具有放射性。超聲心動圖由于其具有無創(chuàng)、無放射性、價廉、可重復檢查等優(yōu)點,在臨床作為監(jiān)測心臟形態(tài)結構和功能的首選檢查手段,不僅能夠清晰觀察心臟的結構,而且還能評價心臟的功能。本研究目的旨在應用二維超聲心動圖和斑點追蹤技術對腎移植術后左室結構及功能進行監(jiān)測,探討腎移植術后左室結構和功能的改變,從而為臨床提供更大的幫助。 本研究分為以下三部分： 第一部分：尿毒癥患者左室重構與收縮功能的超聲評價 本部分以67例尿毒癥作為研究對象,根據(jù)左室射血分數(shù)(EF)分為EF正常組(47例)和EF減低組(20例)。獲取左室長軸切面,應用二維超聲心動圖測量并計算舒張末期左室內(nèi)徑(LVEDD)、舒張末室間隔厚度(IVST)。舒張末左室后壁厚度(PWT)、左室質(zhì)量(LVM)、左室質(zhì)量指數(shù)(LVMI)。應用雙平面Simpson法計算左室射血分數(shù)(EF)。獲取左室乳頭肌短軸切面、心尖四腔切面應用斑點追蹤成像(STI)技術測量并記錄左室整體環(huán)向收縮期峰值應變(GCS)、徑向收縮期峰值應變(GRS)、縱向收縮期峰值應變(GLS)。探討尿毒癥患者左室結構及收縮功能改變。結果①與對照組相比,尿毒癥患者收縮壓、舒張壓、脈壓,心率增高,其中EF減低組較EF正常組心率增快,收縮壓增高,差異有統(tǒng)計學意義(P0.05)。②與對照組比較,尿毒癥患者LVEDD擴大,IVST、PWT增厚,LVM及LVMI增大,且EF減低組較EF正常組改變更明顯,差異有統(tǒng)計學意義(P0.05)。③與對照組相比,尿毒癥組GCS、GRS、GLS均減低,并且EF減低組左室應變測值較EF正常組進一步減低,差異有統(tǒng)計學意義(p0.05)。 第二部分尿毒癥患者腎移植術后左室重構的超聲評價 本研究以30例腎移植患者為研究對象,于術前、術后3月、術后6月、術后12月進行超聲檢查,二維超聲心動圖測量并計算左室參數(shù)：舒張末期左室內(nèi)徑(LVEDD)、舒張末室間隔厚度(IVST)、舒張末左室后壁厚度(PWT)、左室質(zhì)量(LVM)、左室質(zhì)量指數(shù)(LVMI)。應用雙平面Simpson法計算左室射血分數(shù)(EF)。結果①尿毒癥患者收縮壓、舒張壓、脈壓于術后3個月、6個月、12個月較術前明顯減低至正常對照組水平,差異有統(tǒng)計學意義(P0.05)；EF術后3個月、6個月、12個月較術前增高至正常對照組水平,差異有統(tǒng)計學意義(P0.05)。②尿毒癥患者IVST、PWT、LVEDD、 LVM、 LVMI術后3個月、6個月、12個月均較術前減小,差異有統(tǒng)計學意義(P0.05)。③LVMI與SBP (r=0.734, p=0.000)、DBP (r=0.550,p=0.015)、PP (r=0.507, p=0.027)、血肌酐(r=0.539,p=0.017)成正相關,與動靜脈瘺(r=-0.071,p=0.774)、術前透析時間(r=-0.008,p=0.975)、術前EF(r=-0.327,p=0.171)無關。多元回歸分析表明收縮壓是尿毒癥患者術后LVMI的獨立預測因素(β=0.734,p=0.000)。 第三部分STI技術評價尿毒癥腎移植術后患者左室整體收縮功能 本研究以30例腎移植患者為研究對象,于術前、術后3月、術后6月、術后12月進行超聲檢查,獲取左室乳頭肌短軸切面、心尖四腔切面應用斑點追蹤成像(STI)技術測量并記錄左室整體環(huán)向收縮期峰值應變(GCS)、徑向收縮期峰值應變(GRS)、縱向收縮期峰值應變(GLS)。三維超聲心動圖測量左室射血分數(shù)(EF)。結果①與對照組比較,尿毒癥患者術前EF、GCS、GRS、GLS減低,差異有統(tǒng)計學意義(p0.05)；EF術后6個月、12個月較術前增加至對照組水平,差異有統(tǒng)計學意義(p0.05),術后3個月與術前比較差異無統(tǒng)計學意義；GCS、GRS、GLS術后3個月、6個月、12個月較術前增加,但低于對照組,差異有統(tǒng)計學意義(p0.05)。③GCS、GCS、GLS與SBP、DBP、PP、Cr、透析時間、AVF呈負相關。 結論 1、尿毒癥患者左室發(fā)生重構,左室收縮功能減低,超聲斑點追蹤成像技術可早期發(fā)現(xiàn)左室射血分數(shù)正常尿毒癥患者左室收縮功能不全。 2、腎移植可改善尿毒癥患者左室結構、質(zhì)量及收縮功能,隨著術后時間延長,左室結構、質(zhì)量及收縮功能逐漸恢復,但仍較正常人有差異。移植術后LVMI與血壓、血肌酐水平相關。收縮壓是腎移植術后LVMI改變的預測因子。左室收縮功能與血壓、血肌酐、透析時間、AVF相關。 3、超聲技術作為評價尿毒癥患者腎移植術后左室結構和功能改變的隨訪工具。
[Abstract]:Preface
A variety of end-stage chronic kidney disease manifestations of uremia, significantly increased the risk of death and cardiovascular disease. Cardiovascular events are the leading cause of death in patients with uremia in patients with chronic kidney disease, about 58% died from cardiovascular disease, common for sudden cardiac death and heart failure. Cardiac remodeling for myocardial injury or cardiac load resulting in increased heart size change, shape and function. Left ventricular hypertrophy is one of the most common cardiovascular complications in patients with chronic kidney disease, often indicates poor prognosis. Clinically, 75% adult patients with uremia started dialysis with left ventricular hypertrophy. Uremic heart pathological changes including fibrosis, myocardial hypertrophy, coronary perfusion tissue decreased.
At present, the major treatment for uremic renal transplantation and dialysis. Compared with dialysis, kidney transplantation can significantly reduce mortality, considered end-stage chronic kidney disease treatment of standard.Dzemidzic think that the loss associated with uremia related risk factors of left ventricular mass reduction after transplantation. Evaluation after renal transplantation on left ventricular mass change to evaluate the prognosis of patients has important clinical significance, however, for after kidney transplantation reduces left ventricular mass is still controversial. Early studies showed that cardiac function after renal transplantation significantly improved left ventricular hypertrophy, reduce the.Montanaro that reducing left ventricular mass after renal transplantation, and Patel on the table shows no significant changes in left ventricular quality after renal transplantation. The recent Vaidya studies suggest that most patients with reduced left ventricular mass after transplantation, there is still a small number of patients with left ventricular mass did not change significantly, and the left ventricular mass The degree of reduction was related to the degree of preoperative hypertrophy.
Kidney transplantation with maintenance hemodialysis patients had a higher survival rate, USRDS data showed that the mortality of patients undergoing renal transplantation was significantly higher than routine dialysis patients is low. However, the annual renal transplant patients suffered non fatal cardiovascular events rate is 50 times that of the general population, died of heart failure incidence is 10 times that of the general population. The study pointed out that after transplantation contraction dysfunction in patients with cardiovascular mortality than systolic function in normal renal transplant patients increased, therefore, the left ventricular systolic function assessment in renal transplantation has important significance.
The clinical evaluation of left ventricular structure and function of the technology of magnetic resonance imaging, radionuclide angiocardiography, CT, cardiac catheterization and echocardiography. Magnetic resonance imaging is considered the gold standard for assessment of left ventricular structure and function, but the examination cost is expensive, check for a long time, there are some contraindications, limit it is widely used in clinic; radionuclide angiography, cardiac catheterization, aggressive; CT examination is radioactive. Echocardiography because it is non-invasive, non radioactive, inexpensive, reproducible inspection etc., as the preferred method for examination of the morphology and function of cardiac monitoring in clinic, not only can clearly observe the heart the structure, function and also to evaluate the heart. The purpose of this study is to use two-dimensional echocardiography and speckle tracking technology to monitor the structure and function of left ventricular in patients after renal transplantation of kidney The changes in the structure and function of the left ventricle after transplantation provide greater help to the clinic.
This study is divided into the following three parts:
The first part: echocardiographic evaluation of left ventricular remodeling and systolic function in patients with uremia
鏈儴鍒嗕互67渚嬪翱姣掔棁浣滀負鐮旂┒瀵硅薄,鏍規(guī)嵁宸﹀灝勮鍒嗘暟(EF)鍒嗕負EF姝ｅ父緇，

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