心力衰竭(HF)是终末期肾病(ESKD)的严重并发症。然而,大多数数据来自回顾性研究,这些研究包括开始时接受慢性血液透析的患者.这些患者经常水分过多,这显著影响了超声心动图的发现。这项研究的主要目的是分析心力衰竭的患病率及其表型。次要目的是(1)描述N末端脑钠肽前体(NTproBNP)在血液透析的ESKD患者中诊断HF的潜力,(2)剖析左心室几何形状异常的频率,和(3)描述该人群中各种HF表型之间的差异。
■我们纳入了五个愿意参与的血液透析单位中所有接受至少3个月慢性血液透析的患者,没有活体肾移植捐献者,纳入时的预期寿命超过6个月。详细的超声心动图和血液动力学计算,透析动静脉内瘘流量计算,和基础实验室分析在临床稳定的条件下进行。通过临床检查和使用生物阻抗排除了严重的过度水合。
■共214例患者,年龄66.4±14.6岁。其中57%被诊断为HF。在HF患者中,保留射血分数的HF(HFpEF)为,到目前为止,最常见的表型,发生在35%,而射血分数(HFrEF)降低的HF仅发生在7%,HF轻度降低射血分数(HFmrEF)为7%,9%的高输出HF。HFpEF患者与无HF患者在以下方面存在显着差异:他们年龄较大(62±14vs.70±14,p=0.002),左心室质量指数[96(36)vs.108(45),p=0.015],左心房指数较高[33(12)vs.44(16),p<0.0001],和更高的估计中心静脉压[5(4)vs.6(8)、p=0.004]和肺动脉收缩压[31(9)vs.40(23)、p=0.006],但三尖瓣环平面收缩期偏移稍低(TAPSE):22±5vs.24±5,p=0.04。NTproBNP对诊断HF或HFpEF的敏感性和特异性较低:使用8,296ng/L的临界值,HF诊断的敏感性仅为52%,而特异性为79%。然而,NTproBNP水平与超声心动图变量显着相关,对左心房容积指数(R=0.56,p<10-5)和肺动脉收缩压估计值(R=0.50,p<10-5)影响最大.
■HFpEF是迄今为止慢性血液透析患者中最常见的心力衰竭表型,其次是高输出HF。患有HFpEF的患者年龄较大,不仅具有典型的超声心动图变化,而且水合作用也较高,这反映了两个心室的充盈压力均高于无HF的患者。
UNASSIGNED: Heart failure (HF) is a serious complication of end-stage kidney disease (ESKD). However, most data come from retrospective studies that included patients on chronic hemodialysis at the time of its initiation. These patients are frequently overhydrated, which significantly influences the echocardiogram findings. The primary aim of this study was to analyze the prevalence of heart failure and its phenotypes. The secondary aims were (1) to describe the potential of N-terminal pro-brain natriuretic peptide (NTproBNP) for HF diagnosis in ESKD patients on hemodialysis, (2) to analyze the frequency of abnormal left ventricular geometry, and (3) to describe the differences between various HF phenotypes in this population.
UNASSIGNED: We included all patients on chronic hemodialysis for at least 3 months from five hemodialysis units who were willing to participate, had no living kidney transplant donor, and had a life expectancy longer than 6 months at the time of inclusion. Detailed echocardiography together with hemodynamic calculations, dialysis arteriovenous fistula flow volume calculation, and basic lab analysis were performed in conditions of clinical stability. Excess of severe overhydration was excluded by clinical examination and by employing bioimpedance.
UNASSIGNED: A total of 214 patients aged 66.4 ± 14.6 years were included. HF was diagnosed in 57% of them. Among patients with HF, HF with preserved ejection fraction (HFpEF) was, by far, the most common phenotype and occurred in 35%, while HF with reduced ejection fraction (HFrEF) occurred only in 7%, HF with mildly reduced ejection fraction (HFmrEF) in 7%, and high-output HF in 9%. Patients with HFpEF differed from patients with no HF significantly in the following: they were older (62 ± 14 vs. 70 ± 14, p = 0.002) and had a higher left ventricular mass index [96(36) vs. 108(45), p = 0.015], higher left atrial index [33(12) vs. 44(16), p < 0.0001], and higher estimated central venous pressure [5(4) vs. 6(8), p = 0.004] and pulmonary artery systolic pressure [31(9) vs. 40(23), p = 0.006] but slightly lower tricuspid annular plane systolic excursion (TAPSE): 22 ± 5 vs. 24 ± 5, p = 0.04. NTproBNP had low sensitivity and specificity for diagnosing HF or HFpEF: with the use of the cutoff value of 8,296 ng/L, the sensitivity of HF diagnosis was only 52% while the specificity was 79%. However, NTproBNP levels were significantly related to echocardiographic variables, most significantly to the indexed left atrial volume (R = 0.56, p < 10-5) and to the estimated systolic pulmonary arterial pressure (R = 0.50, p < 10-5).
UNASSIGNED: HFpEF was by far the most common heart failure phenotype in patients on chronic hemodialysis and was followed by high-output HF. Patients suffering from HFpEF were older and had not only typical echocardiographic changes but also higher hydration that mirrored increased filling pressures of both ventricles than in those of patients without HF.