2022 年第 5 期 第 17 卷

射血分数降低型急性心力衰竭患者院内肾功能恶化与容量状态的关系及其对预后的影响

Relationship between worsening renal function and volume status in inpatients with acute heart failure with reduced ejection fraction and its impact on prognosis

作者：冯斯婷1范婧尧1王溪1白杉1贾立昕2

英文作者：Feng Siting1 Fan Jingyao1 Wang Xi1 Bai Shan1 Jia Lixin2

单位：1首都医科大学附属北京安贞医院急诊危重症中心北京市心肺血管疾病研究所，北京100029；2首都医科大学附属北京安贞医院心力衰竭中心北京市心肺血管疾病研究所，北京100029

英文单位：1Department of Emergency and Critical Care Center Beijing Anzhen Hospital Capital Medical University Beijing Institute of Heart Lung and Blood Vessel Diseases Beijing 100029 China; 2Heart Failure Center Beijing Anzhen Hospital Capital Medical University Beijing Institute of Heart Lung and Blood Vessel Diseases Beijing 100029 China

关键词：急性心力衰竭；射血分数降低型心力衰竭；肾功能恶化；充血

英文关键词：Acuteheartfailure;Heartfailurewithreducedejectionfraction;Worseningrenalfunction;Congestion

• 摘要：

• 目的 分析射血分数降低型急性心力衰竭（AHF）患者住院期间肾功能恶化（WRF）与容量状态的关系及其对预后的影响。方法对2013—2017年国际多中心、随机、双盲、对照研究进行事后分析，从AHF住院患者中纳入左心室射血分数<30%（射血分数降低型AHF）患者1 543例，根据住院5 d内有无WRF，分为无WRF组（1 187例）和WRF组（356例）。评估患者容量状态、住院5 d内WRF及利尿剂治疗情况，研究终点为出院后30 d因心力衰竭再入院率以及180 d心血管死亡和因心力衰竭肾衰竭再入院的复合终点。结果 年龄、基线时收缩压水平和贫血（即血红蛋白减少）为WRF的危险因素（均P<0.05）；而基线时液体潴留相关指标如肺部湿啰音≥1/3肺野（危险比=0.56，95%置信区间：0.39～0.81，P=0.002）、下肢水肿（危险比=0.76，95%置信区间：0.58～0.99，P=0.002）及总胆红素（危险比=0.98，95%置信区间：0.97～0.99，P=0.004）则是WRF的保护性因素。经利尿后复合残余临床充血评分高（危险比=1.08，95%置信区间：1.02～1.13，P=0.003）与WRF发生率增加有关。Kaplan-Meier曲线分析结果表明WRF不影响患者30 d和180 d的临床结局（均P>0.05）。结论  射血分数降低型AHF患者就诊时容量负荷过重与院内利尿治疗后WRF发生率低相关，利尿治疗未增加WRF风险，且院内WRF不影响患者临床预后。

  
  

• Objective  To analyze the relationship between worsening renal function (WRF) and volume status in inpatients with acute heart failure(AHF) with reduced ejection fraction and its impact on prognosis. Methods A post hoc analysis of the international multicenter, randomized, double-blind and controlled study from 2013 to 2017 was carried out. Totally 1 543 inpatients of AHF with left ventricular ejection fraction<30%(AHF with reduced ejection fraction) were included. According to the presence or absence of WRF within 5 d after admission, they were divided into non WRF group(1 187 cases) and WRF group (356 cases), and the volume status, WRF within 5 d after admission and diuretic treatment were evaluated. The end points were the readmission rate due to heart failure 30 d after discharge, and composite cardiovascular death and readmission due to heart failure and renal failure 180 d after discharge. Results  Age, systolic blood pressure at baseline and anemia(decreased hemoglobin) were risk factors for WRF(all P<0.05); at baseline, the relevant indicators of fluid retention such as lung rale appeared more than 1/3 of whole lung (hazard ratio=0.56, 95% confidence interval: 0.39-0.81, P=0.002), lower limb edema(hazard ratio=0.76, 95% confidence interval: 0.58-0.99, P=0.002) and total bilirubin(hazard ratio=0.98, 95% confidence interval: 0.97-0.99, P=0.004) were protective factors for WRF. The high score of combined residual clinical hyperemia after diuresis(hazard ratio=1.08, 95% confidence interval: 1.02-1.13, P=0.003) was associated with the increased incidence of WRF. Kaplan-Meier curve analysis showed that WRF did not affect the clinical outcome of patients at 30 and 180 d (both P>0.05). Conclusions Clinical congestion in patients with AHF with reduced ejection fraction is associated with a lower incidence of WRF during hospitalized diuresis. Diuresis does not increase the risk of WRF, and WRF during hospitalization does not affect patients′ outcomes.