| Objective: To investigate the relationship between the level of cardiac function before peritoneal dialysis(PD)in patients with end-stage renal disease(ESRD)and the risk of heart failure during the PD.To study the risk factors of cardiovascular risk before and after PD,and the impact of primary disease,adequacy of dialysis on cardiovascular events.Materials and Methods: This study was retrospectively analyzed the medical records of 71 patients with ESRD who were initially exposed to PD for more than 3months from January 2016 to January 2018 at the PD Center of Shanghai General Hospital.According to the degree of cardiac insufficiency at the time of admission,and based on the heart function classification of New York Heart Association(NYHA),heart function grade I was classified as group A without obvious cardiac insufficiency,and cardiac function grade II was classified as group B with mild cardiac insufficiency and cardiac function grade III and IV were assigned to group C with moderate to severe cardiac insufficiency.According to the difference in the adequacy of PD,divided into sufficient group for dialysis and insufficient group for dialysis.Collected medical records of patients,including general conditions(age,gender,and primary disease)and clinical indicators,such as inhemoglobin(Hb),serum albumin(Alb),estimated glomerular filtration rate(eGFR),triglyceride(TG),total cholesterol(TC),brain natriuretic peptide(BNP)and so on.The characteristics of changes in clinical indicators before and after PD were studied in groups.SPSS22.0 statistical software was used for statistical analysis.Quantitative data are expressed by mean?standard deviations,and comparison between groups using t testor rank sum test.Qualitative data are expressed by frequency,using chi-square test.A P-value <0.05 was considered statistically significant.The ROC curve was used to analyze the diagnostic effect of each index.The risk factors of CVD in PD patients were analyzed by the two variables Logistics regression.The COX proportional model was used to analyze the risk factors for cardiovascular complications before and after dialysis in patients with ESRD by univariate and multivariate analysis.Results:(1)This study included a total of 71 patients with ESRD(follow-up time 3 months to 18 months).There were 36 patients with no significant cardiac insufficiency,23 patients with mild cardiac insufficiency,and 12 patients with moderate-to-severe cardiac insufficiency before the initial PD.According to the clinical manifestations,laboratory tests and Kt/V levels,there were 41 patients in the adequate dialysis group and 25 patients in the incomplete dialysis group,and five patients could not determine the adequacy of dialysis because of missing clinical data.(2)Compared the index before initial PD in ESRD patients with different heart function levels,found out the degree of cardiac insufficiency in group A,B and C before dialysis were closely related to the levels of BNP,cystatin C(Cys-C),BUN,eGFR,LVEF before PD(156.65±177.87 vs 358.01±288.34 vs 981.38±717.62;4.80±1.36 vs 5.68±1.34 vs 5.90±1.15;25.34±7.54 vs 31.53±9.61 vs 28.75±9.25;6.84±2.17 vs 4.91±1.95 vs 6.72±2.32;0.63±0.04 vs 0.61±0.04 vs 0.55±0.07;P<0.05).(3)Compared the correlative indexes of patients with ESRD with different levels of heart function in PD.It was found that the degree of cardiac insufficiency in groups A,B and C before dialysis were closely related to the level of BNP,Alb,LVEF and myoglobin in dialysis(87.71±95.81 vs 296.49±444.50 vs 435.17±405.26;32.78±3.62 vs 29.73±5.30 vs 29.24±4.87;0.64±0.03 vs 0.62±0.03 vs 0.55±0.09;132.66±63.78 vs 231.32±195.69 vs 200.05±157.99;P<0.05).(4)To compare the differences in ESRD patients between three different levels of cardiac function beforeand after dialysis.Among those patients with no significant cardiac insufficiency whose the level of Hb was significantly increased(-24.68±18.43,P<0.05),the level of BNP,ferritin were significantly decreased(62.12±145.85;77.26±112.81;P<0.05)in dialysis.And those patients with mild cardiac insufficiency whose the level of Hb was significantly increased(-20.20±19.90,P<0.05),the level of homocysteine(HCY),PTH,serum phosphate,ferritin were significantly decreased(11.64±6.44;65.90±119.91;0.36±0.71;106.92±166.05;P<0.05)in dialysis.The patients with moderate-to-severe cardiac insufficiency whose the level of Hb was significantly increased(-21.93±27.19,P<0.05),the level of BNP,serum calcium,ferritin were significantly decreased(603.15±702.91;0.12±0.13;220.84±152.43;P<0.05)in dialysis.(5)The ROC curve showed LVEF(95% CI: 0.552-0.848,P=0.024),urinary albumin/urine creatinine(uAlb/uCr)(95% CI: 0.616-0.885,P=0.003)had diagnostic value for the occurrence of cariovascular events before PD,and the smaller the LVEF,the more likely occurrence.When the LVEF is 0.605,it is the best diagnostic cutoff point with the sensitivity of 0.714 and the specificity of 0.688.On the contrary,the larger the uAlb/uCr,the more likely occurrence.When uAlb/uCr is 1596.39,it is the best diagnostic cut-off point with the sensitivity of 0.933 and the specificity of 0.608.Besides,eGFR(95%CI: 0.559-1.000,P=0.012),Alb(95%CI: 0.772-0.971,P=0.001),uAlb/ uCr(95%CI: 0.796-0.979,P=0.002)had diagnostic value for the occurrence of cariovascular events in PD,and the smaller the eGFR,the more likely occurrence.When the eGFR is 3.59,it is the best diagnostic cutoff point with the sensitivity of0.714 and the specificity of 0.944.The smaller the Alb,the more likely occurrence.When the Alb is 30.55,it is the best diagnostic cutoff point with the sensitivity of 1and the specificity of 0.717.On the contrary,the larger the uAlb/uCr,the more likely occurrence.When uAlb/uCr is 1999.9,it is the best diagnostic cut-off point with the sensitivity of 1 and the specificity of 0.837.(6)The adequacy of PD has nosignificant effect on heart failure(OR=0.386,95%CI: 0.078-1.913,P=0.244>0.05).(7)Compared the differences in serum calcium,serum phosphorus,calcium-phosphorus product,and serum ferritin in different primary PD patients before and after dialysis.It was found that the level of serum ferritin was significantly decreased in patients with diabetic nephropathy(DN)in dialysis(104.85±153.29,P<0.05);the levels of serum phosphate,calcium-phosphorus product,serum ferritin were decreased in patients with hypertensive nephropathy in dialysis(0.21±0.62;4.29±16.14;94.49±141.84;P<0.05);the levels of serum phosphate,serum ferritin were decreased in patients with chronic glomerulonephritis in dialysis(0.29±0.57;83.73±136.30;P<0.05),and the level of calcium-phosphorus product was also decreased in dialysis(rank sum test: t=2.241,P=0.028<0.05);the level of serum calcium was decreased in patients with other secondary nephropathy in dialysis(0.22±0.16,P<0.05).(8)Univariate COX regression analysis showed that CK-MB was the risk factor of CVD for patients of ESRD before PD(OR=1.271,95%CI: 1.009-1.599,P=0.041);Hb(OR=0.936,95%CI: 0.880-0.996,P=0.036),Alb(OR=0.755,95%CI:0.611-0.934,P=0.010),and eGFR(OR=0.549,95%CI: 0.327-0.924,P=0.024)were the risk factors of CVD for patients of ESRD in PD(P<0.05).Multivariate COX regression analysis further suggested that LVEF of pre-dialysis(OR=0.00002,95%CI:0.000-0.573,P=0.041)and Alb of dialysis(OR=0.750,95%CI: 0.571-0.987,P=0.040)had significant effects on heart failure in patients.Conclusions:(1)The degree of cardiac insufficiency in pre-dialysis is closely related to the risk of heart failure during the dialysis.(2)The PD can reduce heart failure in ESRD patients with different heart function level.(3)LVEF,uAlb/ uCr are influence factors of cardiovascular disease(CVD)before PD.eGFR,Alb,uAlb/ uCr are influence factors of CVD in PD.(4)There is no obvious relationship between adequacy of PD and heart failure.(5)The patients of ESRD which DN,hypertensivenephropathy,chronic glomerulonephritis were reduced microinflammatory status in PD.(6)The high CK-MB and low LVEF of pre-dialysis is independent risk factor for CVD;The anemia,hypoproteinemia,and low eGFR of dialysis are independent risk factors for CVD. |
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