1、Zhang Juan, Jia Dalin Abstract Objective : To evaluate the relationship between mild renal dysfunction and coronary artery stenosis. Methods :272 cases of coronary artery stenosis undergoing coronary angiography were divided into two groups, the one is normal renal function group (Glomerular filtrat
2、ion rate, GFR1.73m2)and mild renal dysfunction group (Glomerular filtration rate, 601.73m2) . The severity of coronary stenosis was quantified with angiography image manipulation system and scored according to lesions ,so to analyze the quantitive and qualitative relationship between mild renal dysf
3、unction and coronaryartery stenosis. Results : the score of the coronary artery stenosis for the normal renal function group is23.767.25, the score of the coronary artery stenosis for the mild renal dysfunction group is 26.8718.69,there was a remarkable negative correlation between the two groups(p9
4、0ml/(kg1.73m2)135 例 ,肾功能轻度减退组60排除标准:左室射血分数30%、恶性肿瘤、严重全身炎症及免疫性反应、严重肝功能损害、严重肾功能不全(其标准是?GFR?小于多少)或是需要透析治疗的患者。 根据Cockcroft-Gault5公式计算GFR即GFR=(140-年龄)体重1.23(男)或1.05(女)血清肌酐值1.2冠状动脉造影及分析 各例以标准Judkins造影法行冠状动脉造影,用PHILIPS FD-10血管造影机进行多部位造影,用改良Gensini法6进行冠状动脉病变积分,0.05)。详见附表 2。2 冠脉总狭窄积分在肾功能轻度减退组中明显增高(P 0.05),有显
5、著的统计学差异。详见附表 3 。3 相关分析显示肾小球滤过率和总狭窄指数呈相关关系(r = 0.584, P 0.05吸烟 (人)101930.777年龄 (岁)66.18.465.47.61.019SBP (mmHg)152.01915017.51.277DBP (mmHg)89.09.588.00121.078FBS (mmol/ L)5.840.795.800.960.531LDL-C (mmol/ L)2.55 0.682.63 0.70-1.356TC(mmol/ L)4.53 0.974.42 0.901.375TG(mmol/ L)1.81 0.981.96 1.22-1.579
6、UA(umol/ L)32989322920.902HDL-C(mmol/L)1.15 0.261.18 0.25-1.364附表3 两组之间的冠脉狭窄积分比较肾功能正常者T冠脉病变积分26.8718.6923.767.252.55850的独立危险因素10。本文由于研究入选病例均为心源性胸痛住院治疗患者,所以无法停用相关药物。我们通过统计学分层随机化,以使药物因素比较均匀地分布于观察组和正常对照组,从而减少因药物影响血生化检查结果而对研究造成的误差。排除药物影响后,本文结果表明,轻度肾功能不全组和肾功能正常组两组在年龄、性别、吸烟、血压、血糖、血脂、血尿酸等传统冠心病危险因素上无显著差异情况下
7、,而两组间的冠脉狭窄积分存在显著差异(p0.05),同时直接对冠状动脉病变进行定量测定后发现轻度肾功能不全GFR值和冠脉狭窄程度之间存在正相关(r=0.585,P0.05),因此说明轻度肾功能不全独立于其他冠心病的易患因素并且可作为预测冠状动脉病变严重程度的指标之一。轻度肾功能不全和冠脉病变关系的具体病理生理机制尚不清楚,目前的研究主要是慢性肾功能不全患者常同时存在高血压、高血脂、糖尿病及吸烟等危险因素,同时由于氧化应激高、同型半胱氨酸血症、炎症标志物增高及钙磷代谢异常造成血管重构和血管顺应性下降,加速血管粥样硬化的形成。其中氧化应激、炎症标志物的升高、高同型半胱氨酸血症等尤其引人关注。70
8、ml/(min1.73m2)的患者血半胱氨酸水平高达100umol/L(正常人12umol/L)高半胱氨酸血症可以导致内皮损伤,血小板聚集,凝血因子增生及平滑肌增生等一系列致动脉粥样硬化等危险因素的增加11。Shlipka等研究5808例心血管健康研究发现,轻度肾功能不全者多伴有CRP、白细胞介素-6、纤溶酶原、因子等炎症及凝血因子活性增加,而这些炎症因子及凝血因子活性增加与冠心病密切相关12。CRP直接参与了动脉粥样硬化的病灶的形成,CRP的升高和内皮细胞功能损害及动脉粥样硬化的进程相关13:1 CRP激活斑块中的补体成分,使斑块不稳定。2 CRP刺激巨噬细胞产生凝血酶原组织因子。3 CRP
9、诱导粘附因子在内皮细胞上的表达。4 单核细胞上的CRP受体能够帮助单核细胞进入血管壁。慢性肾病对冠心病发病和预后的影响具体的肾功能不全导致冠心病易患性增加的机制尚不清楚,有待进一步的研究。慢性肾功能不全对于冠心病的发生及发展起到重要作用。因此,我们应重视对患者的肾功能进行评价,除更严格地控制高血压、糖尿病、脂代谢异常等共同危险因素外,尚需积极地改善其肾功能情况,以改善其发病率及远期预后。参考文献1Culleton BF, Larson MG, Wilson PW, et al. Cardiovascular disease and mortality in a community-based
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