四种不同类型心肾综合征的危险因素探析

分类号：R541.4 学校代码：1 0 0 6 2密级：学号：2012602335学位类别：科学学位☑专业学位☐学科门类：医学硕士学位论文MASTER’S DISSERTATION论文题目：四种不同类型心肾综合征的危险因素分析T I T L E : The Analysis of Factors of FourDifferent Kinds of Cardiorenal Syndromes一级学科：临床医学二级学科：内科学心血管病论文作者：陈琳指导教师：袁如玉教授导师组成员：天津医科大学研究生院二O一五年五月学位论文原创性声明本人郑重声明：所呈交的论文是我个人在导师指导下独立进行研究工作取得的研究成果。

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（请在相对应的方框内打“√”）学位论文作者签名：日期：年月日导师签名：日期：年月日中文摘要目的：分析及总结四种不同类型心肾综合征患者的危险因素，以期能更好的预防及延缓心肾综合征的发生。

方法：回顾性收集天津医科大学第二医院心脏科及肾内科2012年01月至2014年1月住院的心功能不全及肾功能不全患者的临床资料，分为四组，A组为急性心功能不全的患者，根据有无急性肾损害分为I型CRS组（有急性肾损害）和其对照组（无急性肾损害）；B组为慢性心功能不全的患者，根据有无慢性肾功能不全分为Ⅱ型CRS组（有慢性肾功能不全）和其对照组（无慢性肾功能不全）；C 组为急性肾功能不全的患者，根据有无心脏损害或心功能不全分为Ⅲ型CRS组（有心脏损害或心功能不全）和其对照组（无心脏损害或心功能不全）；D组为慢性肾功能不全患者，根据有无心脏损害或心功能不全分为Ⅳ型CRS组（有心脏损害或心功能不全）和其对照组（无心脏损害或心功能不全）。

进而分析四种类型心肾综合征的危险因素。

结果：1. A组共204例，其中对照组为108例，I型CRS组为96例。

单因素分析显示既往存在心衰发作史、高血压、贫血、高尿酸血症、低射血分数、高心功能分级、入院尿素氮和肌酐水平在两组间存在差异，且差异有统计学意义。

进一步Logistic回归分析表明既往存在心衰发作史、入院肌酐水平高是发生I型CRS的危险因素。

2. B组共150例，其中对照组79例，Ⅱ型CRS组为71例。

通过单因素分析显示年龄、冠心病、高血压、糖尿病、贫血、低白蛋白血症、高尿酸血症、低射血分数、高心功能分级、BNP水平在两组间存在差异，且差异有统计学意义。

进一步Logistic回归分析表明年龄、冠心病、高血压、高尿酸血症、贫血、低白蛋白血症、心功能分级高是发生Ⅱ型CRS的危险因素。

3. C组共115例，其中对照组68例，Ⅲ型CRS组47例。

通过单因素分析显示年龄、高血压、冠心病、院内进行血液透析、高尿酸血症、低白蛋白血症、高心功能分级、入院尿素氮水平、肌酐水平、估算肾小球滤过、血钾等在两组间的差异存在统计学意义。

进一步Logistic回归分析表明年龄、心功能分级高、冠I心病、高血压、高血钾、入院肌酐水平高、估算肾小球滤过率低是发生Ⅲ型CRS 的危险因素。

4. D组共210例，其中对照组94例，Ⅳ型CRS组116例。

通过单因素分析显示年龄、高血压、贫血、高尿酸血症、BMI指数高、入院收缩压、尿素氮、肌酐、估算肾小球滤过低、血钾、空腹血糖、甘油三脂，等在两组间的差异有统计学意义。

进一步Logistic回归分析表明年龄、BMI值高、高血尿酸、贫血、入院肌酐水平高、估算肾小球滤过率低、高甘油三脂发生是Ⅳ型CRS的危险因素。

结论：1.Ⅰ型心肾综合征的危险因素主要包括既往存在心衰发作史、入院肌酐水平高。

2.Ⅱ型心肾综合征的危险因素主要包括年龄、心功能分级高、冠心病、高血压、高血尿酸、贫血、低白蛋白。

3.Ⅲ型肾心综合征的危险因素主要包括年龄、心功能分级高、冠心病、高血压、高血钾、入院肌酐水平高、估算肾小球滤过率低.4.Ⅳ型肾心综合征的危险因素主要包括年龄、BMI高、高血尿酸、贫血、入院肌酐水平高、估算肾小球滤过率低、甘油三脂高。

5.心肾综合征危险因素较多，纠正危险因素有可能预防或减缓心肾综合征的发生。

关键词：急性肾损伤慢性肾脏病急性心功能不全慢性心功能不全心肾综合征危险因素IIAbstractObjective: To analyse and summarize the risk factors of patients with four different kinds of cardiaorenal syndromes, and expected that control the hazard factors can benefit for preventing or delaying cardioenal syndromes.Methods:A totale of 679 patients with cardiac dysfunction or renal dysfunction were selected from Jan 2012 to Jan 2014 in the Second Hospital of Tianjin Medical University, and their clinical datas were rospectively analyzed. According to the clinical classification of cardiorenal syndromes, they were divided into four groups: Group A: type 1 CRS group and its control group; Group B: type 2 CRS group and its control group; Group C: type 3 CRS group and its control group; Group D: type 4 CRS group and its control group. Then analysed and summarized the risk factors of patients with four different kinds of cardiac renal syndromes.Results:1. Group A included 204 cases, control group contained 96 ceses and type 1 CRS group contained 108 cases. History of heart failure, hypertention, anemia, hyperuricemia, patients with low ejection fraction,patients with high cardiac function classification,urea nitrogen and creatinine were statistically different between control group and type 1 CRS group evaluated using univariate logistic regression analysis. However ,multivariable logistic analysis revealed that risk factors of type 1 CRS included patients with history of heart failure and high creatinine.2. Group B included 150 cases, control group contained 79 ceses and type 2 CRS group contained 71 cases . Age, Coronary Heart Disease, hypertention, Diabetes Mellitus, anemia, hypoalbuminemia, hyperuricemia, patients with low ejection fraction, high cardiac function classification, BNP were statistically different between control group and type 2 CRS group, evaluated using univariate logistic regression analysis. However , multivariable logistic analysis revealed that risk factors of type 2 CRS included that older, Coronary Heart Disease, hypertention, hyperuricemia, anemia, hypoalbuminemia, high cardiac function classification.3. Group C included 115 cases, control group contained 68 ceses and type 3 CRSIIIgroup contained 47 cases . Age, hypertention, Coronary Heart Disease, hemdialysis, hypoalbuminemia, high cardiac function classification, urea nitrogen, creatinine, estimated glomerular filtration rate, serum potassium were statistically different between control group and type 3 CRS group evaluated using univariate logistic regression analysis. However , multivariable logistic analysis revealed that risk factors of type 3 CRS included that older, Coronary Heart Disease, hypertention, high cardiac function classification, hyperkalemia, high creatinine levels, low estimated glomerular filtration rate.4. Group D included 210 cases, control group contained 94 ceses and type 4 CRS group contained 116 cases . Age, hypertention, anemia, hyperuricemia BMI, high systolic blood pressure, urea nitrogen, creatinine, estimated glomerular filtration rate, serum potassium, fasting plasma glucose(FBG), triglyceride were statistically different between control group and type 4 CRS group , evaluated using univariate logistic regression analysis. However , multivariable logistic analysis revealed that risk factors of type 4 CRS included that older, high BMI,hyperuricemia, anemia, high creatinine, low estimated glomerular filtration rate, high triglyceride . Conclusion:1. Risk factors of type 1 CRS included patients with history of heart failure and high creatinine.2. Risk factors of type 2 CRS included older, Coronary Heart Disease, hypertention, Hyperuricemia anemia , hypoalbuminemia and high cardiac function classification.3. Risk factors of type 3 CRS included older, Coronary Heart Disease , hypertention high cardiac function classification, hyperkalemia , high creatinine levels, low estimated glomerular filtration rate.4. Risk factors of type 4 CRS included older, high BMI , hyperuricemia, anemia, high creatinine, low estimated glomerular filtration rate,high triglyceride.5.There were several risk factors of cardiorenal syndromes ,so correct the risk factors may benefit for preventing or delaying cardioenal syndromes.Key words:Acute Kidney Injury Chronic Kidney Disease Acute Hear Failure, Chronic Hear Failure CRS risk factors.IV目录中文摘要 (Ⅰ)Abstract (Ⅲ)缩略语/符号说明 (Ⅵ)前言 (1)研究现状、成果 (1)研究目的、方法 (2)四种不同类型心肾综合征的危险因素 (3)对象和方法 (3)结果 (6)讨论 (17)结论 (30)参考文献 (31)发表论文和参加科研情况说明 (36)综述 (37)心肾综合征的分型、机制及生物标志物的研究进展 (37)综述参考文献 (48)致谢 (55)V缩略语/符号说明缩略语英文翻译中文译名ADH antidiruetic hormone 抗利尿激素AKI acute kidney injury 急性肾损伤AKIN acute kidney injury network 急性肾损伤网络工作小组ALB albumin 白蛋白BMI body mass index 体重指数BNP B type natriuretic peptide B型钠尿肽BUN blood urea nitrogen 尿素氮CHF chronic heart failure 慢性心力衰竭CKD chronic kidney disease 慢性肾脏病CRS cardiorenal syndrome 心肾综合征cTn cardiac troponin 肌钙蛋白DBP diastolic blood pressure 舒张压eGFR estimated glomerular filtration rate 估算肾小球滤过率EPO Erythropoietin 促红细胞生成素HDLc high-density lipoprotein cholesterol 高密度脂蛋白胆固醇KDIGO kidney disease improving globaloutcomes 改善全球肾脏病预后工作组LDLc low-density lipoprotein cholesterol 低密度脂蛋白胆固醇LVEF left ventricular ejection fraction 左室射血分数NGAL neutrophilgelatinase associatedlipocalin 中性粒细胞明胶酶相关脂质运载蛋白NT-pro BNP N-terminal pro-Brainn atriureticpeptideN末端前脑钠肽NYHA New York Heart Association 纽约心脏病协会RAAS renin-angiotensin-aldosterone system 肾素-血管紧张素-醛固VI酮系统RIFLE risk, injury, failure, loss, end stagerenal disease 危险级、损伤级、衰竭级、肾功能丧失、终末期肾脏病SBP systolic blood pressure 收缩压SCr serum creatinine 血肌酐SNS sympathetic nervous system 交感神经系统TC total cholesterol 总胆固醇TG triglyceride 甘油三酯UA uric acid 尿酸VII前言研究现状、成果心力衰竭（Heart Failure,HF）是由于心脏结构性或功能性疾病损害心室充盈和射血能力而引起的一组临床综合征[l]，为各种心脏病的严重阶段。