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中华医学超声杂志（电子版）

中华医学超声杂志（电子版） ›› 2018, Vol. 15 ›› Issue (11) : 857 -863. doi: 10.3877/cma.j.issn.1672-6448.2018.11.013

所属专题： 文献；

心血管超声影像学

慢性肾脏病进展对左心房功能的影响
史中青1, 王泓1, 杨斌1,†()   
  1. 1. 210002　南京大学医学院附属金陵医院（南京总医院）超声诊断科
  • 收稿日期:2018-05-21 出版日期:2018-11-01
  • 通信作者: 杨斌

Effect of the progression of chronic kidney disease on left atrial function

Zhongqing Shi1, Hong Wang1, Bin Yang1,†()   

  1. 1. Department of Ultrasound, Jinling Hospital, Medical School of Nanjing University, Nanjing 210002, China
  • Received:2018-05-21 Published:2018-11-01
  • Corresponding author: Bin Yang
  • About author:
    Corresponding author: Yang Bin, Email:
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引用本文：

史中青, 王泓, 杨斌. 慢性肾脏病进展对左心房功能的影响[J/OL]. 中华医学超声杂志（电子版）, 2018, 15(11): 857-863.

Zhongqing Shi, Hong Wang, Bin Yang. Effect of the progression of chronic kidney disease on left atrial function[J/OL]. Chinese Journal of Medical Ultrasound (Electronic Edition), 2018, 15(11): 857-863.

目的

探索在慢性肾脏病（CKD）进展过程中左心房功能和容积的改变情况。

方法

选取CKD患者103例，根据CKD分期将其分为3组：A组50例（CKD1、2期），B组29例（CKD3、4期），C组24例（腹膜透析患者）。对以上患者行传统超声心动学检查，使用左心房斑点追踪技术测量左心房峰值应变、峰值应变率、舒张早期左心房应变、左心房收缩应变，并获得左心房时间-容积曲线计算总排空率、被动排空率及主动排空率，使用方差分析及卡方检验比较各组间的指标差异。

结果

与A组患者相比，B组的左心房峰值应变、峰值应变率及舒张早期左心房应变减低，差异有统计学意义［（35.1±6.0）% vs（30.9±7.7）%，（2.11±0.55）s-1 vs（1.83±0.45）s-1，（25.4±6.1）% vs（18.1±5.7）%，q=3.70、3.28、7.77，P均<0.05］；高血压患病率、室间隔厚度、左心房收缩应变增加，差异有统计学意义［56.0% vs 86.2%，χ2=7.59，P=0.006；（9.8±1.4）mm vs（11.1±2.1）mm，（9.6±3.9）% vs（12.8±5.7）%，q=4.09、4.22，P均<0.05］；C组的左心房峰值应变、舒张早期应变低于A组，差异有统计学意义［（29.5±7.5）% vs（35.1±6.0）%，（19.7±4.7）% vs（25.4±6.1）%，q=4.68、5.70，P均<0.05］；C组的高血压患病率、左心室舒张功能障碍率、左心室质量、左心房容积指数、左心房最大容积、左心房最小容积、左心房收缩前容积均高于A组，差异有统计学意义［95.8% vs 56.0%，54.2% vs16.0%，χ2=12.01、11.61，P均=0.001；（201.7±66.0）g vs（159.5±45.2）g，（35.2±9.0）ml vs （28.1±8.0）ml，（57.0±21.1）ml vs （42.1±15.7）ml，（22.9±19.8）ml vs（13.1±6.7）ml，（38.2±14.6）ml vs（27.1±11.3）ml，q=4.46、3.37、4.84、4.78、4.95，P均<0.05］。与B组相比，C组的糖尿病患病率、左心房收缩应变减低，差异有统计学意义［41.4% vs 8.3%，χ2=7.4，P=0.007；（12.8±5.7）% vs （9.7±4.5）%，q=13.45，P<0.05］；左心室舒张功能障碍率、左心房容积指数、左心房最大容积、左心房最小容积、左心房收缩前容积增加，差异有统计学意义［13.8% vs 54.2%，χ2=9.82，P=0.002；（28.6±8.7）ml vs （35.2±9.0）ml，（41.3±17.5）ml vs（57.0±21.1）ml，（14.1±9.2）ml vs （22.9±19.8）ml，（28.2±13.8）ml vs（38.2±14.6）ml，q=2.81、4.58、3.85、4.00，P均<0.05］。

结论

左心房贮存和通道功能随着CKD的进展而减低，CKD3、4期患者的左心房收缩功能强于CKD1、2期患者及腹膜透析患者。左心房应变参数比左心房容积参数更敏感，能在左心房容积改变之前发现左心房功能的改变。

关键词: 慢性肾脏病, 超声心动图, 左心房, 应变, 心脏功能, 腹膜透析
Objective

To explore the changes of left atrial function and volume in the progression of chronic kidney disease using two-dimensional spot tracking.

Method

A total of 103 patients with CKD were selected and divided into 3 groups according to CKD stage: 50 patients in group A (stage 1 and 2), 29 patients in group B (stage 3 and 4), and 24 patients in group C (peritoneal dialysis patients). The traditional echocardiography and left atrial speckle tracking technology was used to measure left atrial peak strain, early diastolic left atrial strain, and left atrial contraction strain in all patients, and the left atrial time-volume curve was obtained to calculate the total emptying rate, passive emptying rate and active emptying rate. SNK test was used to compare the differences among groups.

Results

Compared with stage 1 and stage 2 patients, the left atrial peak strain and peak strain rate and the early diastolic left atrial strain were reduced in the group of stage 3 and stage 4 patients, and the differences were statistically significant [(35.1±6.0)% vs (30.9±7.7)%, (2.11±0.55)s-1 vs (1.83±0.45)s-1, (25.4±6.1)% vs (18.1±5.7)%, q=3.70, 3.28 and 7.77, both P<0.05]. The prevalence rate of hypertension, IVS and left atrial contraction strain increased [(56% vs 86.2%), (9.8±1.4) mm vs (11.1±2.1) mm, (9.6±3.9)% vs (12.8±5.7)%, χ2=7.59, P=0.006; q=4.09 and 4.22, both P<0.05]. The peak strain and early diastolic strain of peritoneal dialysis patients reduced [(35.1±6.0)% vs (29.5±7.5)%, (25.4±6.1)% vs (19.7±4.7)%; q=4.68 and 5.70, both P<0.05]. The prevalence rate of hypertension, LVM, LVDD, LAVI, LAVmax, LAVmin and LAV pre-A and the prevalence of left atrial enlargement increased [(56.0% vs 95.8%), (159.5±45.2) g vs (201.7±66.0)g, (16.0% vs 54.2%), (28.1±8.0) ml vs (35.2±9.0) ml, (42.1±15.7) ml vs (57.0±21.1) ml, (13.1±6.7)ml vs 22.9±19.8) ml, (13.1±6.7) ml vs (22.9±19.8) ml, (27.1±11.3) ml vs (38.2±14.6) ml, χ2=12.01 and 11.61, both P=0.001; q=4.46, 3.37, 4.84, 4.78 and 4.95, both P<0.05]. Compared with stage 3 and 4 patients, the incidence of diabetes and left atrial contraction strain in peritoneal dialysis patients reduced [(41.4% vs 8.3%), (12.8±5.7% vs (9.7±4.5), χ2=7.4, P=0.007; q=13.45, P<0.05], the rate of left ventricular diastolic dysfunction, LAVI, LAVmax and LAV pre-A increased [(13.8% vs 54.2%), (28.6±8.7ml vs (35.2±9.0) ml, (41.3±17.5) ml vs (57.0±21.1) ml, (14.1±9.2) ml vs (22.9±19.8) ml, (28.2±13.8) ml vs (38.2±14.6) ml, χ2=9.82, P=0.002, q=2.81, 4.58, 3.85 and 4.00, both P<0.05]. Compared with group A, the left atrial reservoir and conduit function of group B decreased, but left atrial volume parameters (including LAVI, left atrial maximum volume, minimum volume and volume before left atrial contraction obtained by speckle tracking) had no significant difference. Left atrial total emptying rate, rate of passive and active emptying can be calculated through left atrial time-volume curve. However, the above three parameters had no significant difference among three groups.

Conclusion

The reservoir and conduit function of left atrium decreased with the aggravation of chronic renal disease, but compared with CKD1, 2 and peritoneal dialysis patients, the left atrial contraction function of CKD3, 4 stage patients increased. In addition, the left atrial strain parameters is more sensitive than the left atrial volume parameters, and we can find the changes of left atrial function before the left atrial volume changes.

Key words: Chronic kidney disease, Echocardiography, Left atrial, Strain, Cardiac function, Peritoneal dialysis
图2 左心房斑点追踪应变率曲线图。图示利用斑点追踪技术获得左心房应变率曲线，测得左心房峰值应变率（红色箭头所示）
图3 左心房斑点追踪时间-容积曲线图。图示利用斑点追踪技术测得左心房最小容积（绿色箭头所示），左心房最大容积（蓝色箭头所示），左心房收缩前容积（粉色箭头所示）
表1 A、B、C组患者一般资料比较［（±s）或例（%）］
组别 例数 年龄（岁） 性别（男/女） BMI（kg/m2） 高血压患病率 糖尿病患病率 心率（次/min）
A组 50 43.1±12.3 28/22 24.3±4.2 28（56.0%） 15（30.0%） 76±12.3
B组 29 46.2±15.3 21/8 23.4±3.9 25（86.2%）a 12（41.4%） 74±12.9
C组 24 41.0±10.5 12/12 21.7±2.7b 23（95.8%）b 2（8.3%）c 80±11.6
统计值 ? F=1.230 χ2=3.150 F=3.874 χ2=16.522 χ2=7.253 F=1.634
P值 ? 0.297 0.207 0.024 <0.001 0.027 0.200
表2 A、B、C组患者二维超声心动图参数比较［（±s）或例（%）］
组别 例数 LAD（mm） RVDDM（mm） IVS（mm） LVDDM（mm）
A组 50 34.8±5.0 22.8±2.7 9.8±1.4 47.0±4.7
B组 29 35.8±5.1 23.6±3.3 11.1±2.1a 47.3±3.9
C组 24 37.8±5.8 23.0±3.2 11.2±1.8b 48.4±4.6
F值 ? 2.742 0.659 6.723 0.816
P值 ? 0.069 0.520 0.002 0.445
组别 例数 LVPW（mm） LVM（g） LVEF（%） LVDD
A组 50 9.4±1.4 159.5±45.2 64.6±4.2 8（16.0%）
B组 29 10.0±2.0 184.9±56.9 64.8±4.4 4（13.8%）
C组 24 10.8±1.8b 201.7±66.0b 62.3±6.3 13（54.2%）bc
F值 ? 5.923 5.464 2.200 15.263
P值 ? 0.004 0.006 0.116 <0.001
表3 A、B、C组患者的左心房功能指标比较（±s）
组别 例数 左心房峰值应变（%） 峰值应变率（s-1） 左心房总排空率（%）
A组 50 35.1±6.0 2.11±0.55 0.696±0.073
B组 29 30.9±7.7a 1.83±0.45a 0.675±0.085
C组 24 29.5±7.5b 1.90±0.5 0.641±0.156
F值 ? 6.700 3.309 2.367
P值 ? 0.002 0.052 0.099
组别 例数 舒张早期左心房应变（%） 左心房被动排空率（%） 左心房收缩应变（%） 左心房主动排空率（%）
A组 50 25.4±6.1 0.358±0.127 9.6±3.9 0.517±0.110
B组 29 18.1±5.7a 0.326±0.119 12.8±5.7a 0.514±0.106
C组 24 19.7±4.7b 0.321±0.127 9.7±4.5c 0.441±0.361
F值 ? 17.706 0.971 4.931 1.321
P值 ? <0.001 0.382 0.009 0.272
表4 A、B、C组患者的左心房容积参数比较［（±s）或例（%）］
组别 例数 LAVI（ml/m2） LAV max（ml） LAV min（ml） LAV pre-A（ml） 左心房扩大
A组 50 28.1±8.0 42.1±15.7 13.1±6.7 27.1±11.3 15（30.0%）
B组 29 28.6±8.7 41.3±17.5 14.1±9.2 28.2±13.8 9（31.0%）
C组 24 35.2±9.0bc 57.0±21.1bc 22.9±19.8bc 38.2±14.6bc 14（58.3%）b
F值 ? 6.184 6.919 6.059 6.509 6.187
P值 ? 0.003 0.002 0.003 0.002 0.045
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