【作者】 何凤玲；

【导师】 刘岩；

【作者基本信息】 暨南大学 ， 内科学， 2010， 硕士

【摘要】 研究背景肾功能不全与慢性心力衰竭的发病率和病死率有关,目前慢性心力衰竭合并肾功能不全的治疗几乎没有确凿循证医学依据。加强慢性心力衰竭的防治是治疗合并肾功能不全的慢性心力衰竭患者的关键,本研究旨在了解其发生情况、临床特征、药物治疗特点,提高临床医生、尤其是心血管科和肾内科临床医师对慢性心力衰竭合并肾功能不全的临床特征及治疗的重视。研究目的：通过回顾性临床病例调查研究,分析慢性心力衰竭住院患者合并肾功能不全的发生率、临床特征、药物治疗特点及肾功能不全对住院时间的影响。研究方法：收集广州市红十字会医院2009年1月～2009.年6月期间慢性心力衰竭住院病例1153例,详细记录病史、入院一般情况、体格检查、实验室结果和其他辅助检查、住院期间详细用药情况等。依据我国改良后的简化MDRD方程计算肾小球滤过率(glomerular filtration rate,GFR):c-aGFR(ml-min-1·1.73m-2)= 186 X[肌酐]-1.154×[年龄]-0.203×1.233(女性×0.742),公式中肌酐的单位采用mg/dl((lmg/dl=88.402umol/L).结合排除标准,将入选的慢性心力衰竭住院患者193例分为A组、B组、C组,即肾功能正常组(GFRS≥90ml-min1·1.73m-2)、肾功能轻度受损组(60≤GFR<90ml-min-1·1.73m-2)、肾功能不全组(GFR< 60ml·min-1·1.73m-2)三组,分析慢性心力衰竭住院患者及其合并肾功能不全的发病率、临床特点、生化结果、药物治疗特点及肾功能不全对住院时间的影响。结果：入选的慢性心力衰竭患者共193例,年龄中位数是75岁；男性93例(48.2%),女性100例(51.8%)。肾功能正常者63例(32.6%),肾功能轻度受损者81例(42.0%),肾功能不全者49例(25.4%)。与肾功能正常、肾功能轻度受损患者相比,肾功能不全患者的年龄较大(P<0.01),其年龄中位数为79岁；高心病(高血压性心脏病)比例较高为32.7%(P<0.01)；心功能NYHA分级Ⅳ级者较多(P<0.01)；合并高血压、糖尿病、贫血、高尿酸血症较多(P<0.01)；且住院时间较长,住院时间中位数为13天(P<0.01)。三组间慢性心力衰竭患者的血红蛋白、血钠浓度、血钾浓度、血清总胆固醇、血肌酐、肾小球滤过率、血尿酸、尿蛋白、超敏C反应蛋白的差异均有统计学意义(P<0.05)。肾功能不全组的血红蛋白及肾小球滤过率较低,血尿酸、血肌酐及超敏C反应蛋白较高,且差异均有统计学意义(P<0.05)。在入选的慢性心力衰竭患者中,利尿剂、钙离子拮抗剂、他汀类、β-受体阻滞剂使用比例较高,分别为75.1%(P<0.01)、72.0%(P>0.05)、69.9%(P>0.05)、61.1%(P<0.01)；洋地黄、血管紧张素转化酶抑制剂(ACEI)的使用较少,分别为10.4%(P>0.05)、25.9%(P<0.05)。结论：慢性心力衰竭住院患者合并肾功能不全的发生率较高,其年龄较大、心功能差、合并高血压、糖尿病、贫血及高尿酸血症较多见,住院时间较长。肾功能不全组的血红蛋白及肾小球滤过率较低,而血尿酸、血肌酐及超敏C反应蛋白较高。慢性心力衰竭住院患者的药物治疗以利尿剂、钙离子拮抗剂、他汀类、β-受体阻滞剂为主,而ACEI的应用比例较低,与指南存在部分差距。更多还原

【Abstract】 Background:In patients with chronic heart failure (CHF), kidney dysfuction was associated with increased morbidity and mortality.Unfortunately,we have no evidence from clinical heart failure trials on which to base about our therapy for patients with renal dysfunction.Therefore,It is ctritical to address preventing and treatment.This study aims to analyze the prevelance、clinical feature and drug treatment.What is more, we want clinical doctors especially experting on cardiology or nephrology to pay attention to the clinical feature and drug treatment of hospitalized chronic heart failure patients with renal dysfunction.Objective: To analyze the prevalence,clinical feature,and drug treatment of hospitalized chronic heart failure(CHF) patients with renal dysfunction.Methods:1153 cases with chronic heart failure were included in research from Red Cross Hospital of Guangzhou from January 2009 to June 2009.Clinical data were recorded including medical history,general case,physical examination,laboratory results,other assistant examination, medication use, hospital stay and so on. Modified glomerular filtration rate (GFR) Estimating Equation for Chinese Patients was used to evaluated the patients’renal function:c-aGFR (ml-min-1·1.73m-2)=186X [Pcr]-1.154X [age]-0.203X 1.233(female×0.742)(Pcr:mg/dl, 1mg/dl= 88.402umol/l).According to GFR,all the patients were divided into three groups:group A (GFR≥90ml-min-1·1.73m-2), group B(60≤GFR< 90ml·min-1·1.73m-2), group C(GFR< 60ml-min-1·1.73m-2).That was the normal renal function group, the mild renal fuction damage group, the renal dysfunction group,respectively.The incidence,clinical feature, drug treatment and the relationship between renal function and hospital stay were analyzed.Results:193 cases were enrolled.The median age of the patients was 75 years old.There were 93 males (48.2%) and 100 (51.8%) famales.63 CHF patients’(32.6%) renal function were normal,81 CHF patients (42.0%) had mild renal function damage,49 CHF patients(25.4%) had renal dysfunction.Compared with the normal renal function group and the mild renal function damage group,the CHF with renal dysfunction patients were elder,whose median age was 79 years old.The major etiology of CHF with renal dysfunction patients was caused by hypertension (32.7%)and cardiac function NYHAIV were more (P<0.01). The complication proportion of hypertension,diabetics, anemia and hyperuricemia was higher(P<0.01).The median hospital stay of CHF with renal dysfunction was 13 day and longest in the three group(P< 0.01). Among the three group of enrolled CHF patients, There was significant difference in laboratory examination,such as haemoglobin,serum sodium, serum potassium, serum total cholesterol, plasma creatinine, glomerular filtration rate, serum uric acid,urine protein, hypersensitive C-reactive protein (P<0.05). What’s more, the CHF with renal dysfunction patients were lower in haemoglobin and glomerular filtration rate,while higher in serum uric acid, plasma creatinine, hypersensitive C-reactive protein (P<0.05). Among the enrolled CHF patients, the major medieation included diuretic(75.1%) (P< 0.01), calcium antagonist(72.0%)(P> 0.05), statins(69.9%)(P>0.05),β-blocker (61.1%) (P<0.01).However,the application ratio of digitalis and angiotensin-converting enzeny inhabitor (ACEI) was 10.4%(P>0.05),25.9%(P<0.01) respectively.Conclusion:The incidence rate of renal dysfunction was higher in hospitalized CHF patients, the CHF patients with renal dysfunction were elder, cardic function much worse and longer hospital stay. What’s more, the CHF with renal dysfunction patients were lower in haemoglobin and glomerular filtration rate,while higher in serum uric acid, plasma creatinine, hypersensitive C-reactive protein.The complication proportion of hypertension,diabetics,anemia, hyperuricemia was common.The drugs such as diuretic, calcium antagonist, statins,β-blocker were the major therapy for the CHF patients.However,the application proportion of ACEI was lower than the guidelines.更多还原