【作者】 李峥；

【导师】 吕冬梅；

【作者基本信息】 吉林大学 ， 临床医学硕士（专业学位）， 2024， 硕士

【摘要】 目的:采用超声分层应变技术,检测左室射血分数正常的慢性肾脏病患者的心肌收缩功能情况,评估亚临床阶段慢性肾脏病患者左心室各层心肌受累程度与肾小球滤过率的相关性。方法:选取2022年12月至2023年12月经我院肾内科确诊为慢性肾脏病的患者,共176例作为实验组。根据2012年国际肾脏病组织“肾脏病:改善全球预后”(KDIGO)指南定义的慢性肾脏病(chronic kidney disease,CKD)分期,按肾小球滤过率(glomerular filtration rate,eGFR)将实验组分为5组:A组为eGFR≥90ml/min,B组为eGFR60-89ml/min,C组为eGFR30-59ml/min,D组为eGFR15-29ml/min,E组为eGFR<15ml/min且未进行透析治疗的患者。并同期于我院选取与实验组年龄、性别相匹配,肾脏功能正常,既往无心脏病及高血压史,心电图、常规心脏超声及实验室检查均正常,共30人作为对照组。受试者连接心电图并左侧卧位,于左心室长轴切面测量收缩末期左房前后径(LAd)、舒张末期左室内径(LVIDd)、舒张末期室间隔厚度(IVST)、舒张末期左室后壁厚度(LVPWT),计算左心室质量指数(Left ventricular mass index,LVMI);于心尖四腔心切面使用双平面Simpson法测量左心室收缩期射血分数(left ventricular ejection fraction,LVEF),舒张早期二尖瓣口血流速度E峰、舒张晚期二尖瓣口血流速度A峰、计算E/A,测量舒张早期二尖瓣环间隔侧(e’m)及二尖瓣环侧壁侧(e’l)心肌运动峰值速度,并计算平均值e’及E/e’。另外采集胸骨旁左室短轴二尖瓣水平、乳头肌水平、心尖水平切面以及心尖四腔心、两腔心、三腔心切面超声心动图像共5个心动周期,储存于硬盘中用于脱机分析。利用QLAB13.0工作站,应用Echo PAC脱机软件中Q-Analysis(2Dstrain)功能,对上述6个切面进行分析,若系统自动追踪显示不满意,可手动调整感兴趣区以获得满意的追踪结果。对心尖四腔心、两腔心、三腔心切面进行描记,得到左心室整体纵向峰值应变(GLS)、内膜层(GLSendo)、中层(GLSmid)及心外膜层纵向应变(GLSepi);再通过对左室短轴二尖瓣水平、乳头肌水平、心尖水平切面进行描记,获得左室整体圆周峰值应变(GCS)、心内膜层(GCSendo)、中层(GCSmid)及心外膜层周向应变(GCSepi)。采用SPSS 27.0软件对采集的各组研究数据进行统计学分析,计数资料比较使用卡方检验,计量资料经正态性检验,以均数±标准差(±s)表示;比较两组数据均值的差异采用独立样本T检验,比较多组间均数采用单因素方差分析(ANOVA),LSD事后检验方法在组间进行两两比较;绘制受试者工作特征曲线(receive operating characteristic curve,ROC)分析应变参数GLS及GCS与肾小球滤过率相关性;通过Pearson相关性分析的方法分析左室各层纵向应变参数与eGFR的相关性。结果:1.一般临床资料的比较:各组间性别、年龄、BMI、心率、舒张压的差异无统计学意义(P>0.05)。与对照组相比,各实验组收缩压均升高(P<0.05)。与D组相比,E组BNP升高(P<0.05)。2.常规超声心动图参数的比较:各组间LAd、LVIDd、LVPWT、LVEF及E峰的差异无统计学意义(P>0.05),但随着肾小球滤过率的降低,LVEF呈下降趋势。与对照组相比,C、D、E组IVST增厚(P<0.05),C、D、E组A峰升高、E/A降低(P<0.05),D、E组e’m、e’l降低,E/e’及LVMI升高(P<0.05)。3.分层应变参数(以绝对值表示)的比较:各组间各层GLS与GCS绝对值均呈现由内膜层向外膜层的递减趋势。与对照组相比,E组GLS、GLSendo、GLSmid、GLSepi、GCS、GCSendo、GCSmid、GCSepi均降低(P<0.05),D组GLSendo降低(P<0.05)。4.ROC曲线:分析GLS及GCS在评估不同肾小球滤过率受试者心肌受损中的预测价值,分析结果显示GLS的曲线下面积(AUC)为0.753,GCS的曲线下面积为0.469,GLS较GCS的预测准确性高。5.Pearson相关性分析:结果显示GLSendo、GLSmid、GLSepi与eGFR呈正相关,且GLSendo与eGFR相关性最紧密。结论:1.心脏舒张功能下降及心室形变早于心脏收缩功能的改变。2.eGFR<15ml/min的慢性肾脏病患者,LVEF虽在正常范围,GLS、GLSendo、GLSmid、GLSepi、GCS、GCSendo、GCSmid、GCSepi均已下降,但以GLSendo下降最明显,提示心内膜下心肌对损伤更为敏感。3.eGFR<30ml/min且LVEF在正常范围的慢性肾脏病患者,在GCS未发生显著改变时,GLSendo已开始下降,提示GLS对于慢性肾脏病患者的心肌损伤评估较GCS敏感。4.分层应变技术较常规超声心动图监测慢性肾脏病患者的相关心肌损伤更敏感。当慢性肾脏病患者心肌受损处于亚临床阶段时,有助于监测心脏功能的改变,早期发现并协助临床诊疗。更多还原

【Abstract】 Objective:To detect the myocardial systolic function of chronic kidney disease patients with normal left ventricular ejection fraction by ultrasonic stratified strain technique,and to evaluate the correlation between the degree of myocardial involvement in each layer of left ventricle and eGFR in patients with subclinical chronic kidney disease.Methods:A total of 176 patients diagnosed with CKD in our hospital from December 2022 to December 2023 were selected as the experimental group.According to the chronic kidney disease(CKD)staging defined by the International Kidney Disease Organization "Kidney Disease:Improving Global Outcomes"(KDIGO)guidelines in 2012,the experimental group was divided into 5 groups according to glomerular filtration rate(eGFR): group A was eGFR≥90ml/min,group B was eGFR60-89ml/min,group C was eGFR30-59ml/min,group D was eGFR15-29ml/min,and group E was eGFR<15ml/min and did not undergo dialysis treatment.At the same time,30 patients with normal renal function,no history of heart-disease and hypertension,normal electrocardiogram,routine cardiac ultrasound and laboratory examination were selected as the control group.The subjects were connected to the electrocardiogram and lying on the left side.The left ventricular end-systolic anterior-posterior diameter(LAd),left ventricular end-diastolic inner diameter(LVIDd),end-diastolic interventricular septum thickness(IVST),end-diastolic left ventricular posterior wall thickness(LVPWT)were measured in the long axis section of the left ventricle,and the left ventricular mass index(LVMI)was calculated.The left ventricular systolic ejection fraction(LVEF),early diastolic mitral valve velocity peak E,late diastolic mitral valve velocity peak A,and the calculation of E/A were measured in the apical four-chamber section.The early diastolic mitral annular septal side(e’m)andmitral annular lateral side(e’l)myocardial peak velocity were measured,and the average e’ and E/e’ were calculated.In addition,five cardiac cycles of echocardiographic images of the parasternal left ventricular short axis at the mitral valve level,papillary muscle level,apical level section,and apical four-chamber,two-chamber,and three-chamber sections were collected,and stored in the hard disk for offline analysis.Using QLAB13.0 workstation,the Q-Analysis(2Dstrain)function in Echo PAC offline software was applied to analyze the above six sections.If the automatic tracking display was unsatisfactory,the area of interest(ROI)could be manually adjusted to obtain satisfactory tracking results.The apical four-chamber heart,two-chamber heart,three-chamber heart section were traced,and the left ventricular global longitudinal peak strain(GLS),endocardium(GLSendo),middle layer(GLSmid)and epicardial layer longitudinal strain(GLSepi)were obtained;then the left ventricular short axis mitral valve level,papillary muscle level,apical level section were traced,and the left ventricular global circumferential peak strain(GCS),endocardium(GCSendo),middle layer(GCSmid)and epicardial layer circumferential strain(GCSepi)were obtained.SPSS 27.0 software was used to carry out statistical analysis on the collected data of each group.The enumeration data were compared by chi-square test,and the measurement data were tested by normality test,expressed as mean ± standard deviation(±s);the difference of the mean value of two groups of data was compared by independent sample T test,the mean values between multiple groups were compared by one-way analysis of variance(ANOVA),and the LSD post-test method was used for pairwise comparison between groups;the receiver operating characteristic curve(ROC)was drawn to analyze the correlation between strain parameters GLS and GCS and glomerular filtration rate,P<0.05 indicated that the difference was statistically significant;the correlation between longitudinal strain parameters of each layer of the left ventricle and eGFR was analyzed by Pearson correlation analysis.Results:1.Comparison of general clinical data: there was no statistically significant difference in gender,age,BMI,heart rate,diastolic blood pressure among the groups(P>0.05).Compared with the control group,the systolic blood pressure increased in all the experimental groups,with statistically significant differences(P<0.05).Compared with group D,BNP increased in group E,with statistically significant differences(P<0.05).2.Comparison of conventional echocardiographic parameters:There was no significant difference in LAd,LVIDd,LVPWT,LVEF and E peak among the groups(P>0.05),but with the decrease of glomerular filtration rate,LVEF showed a downward trend.Compared with the control group,IVST increased in groups C,D and E,with statistically significant differences(P<0.05).The A peak increased and E/A decreased in groups C,D and E,with statistically significant differences(P<0.05).The e’m and e’l decreased and E/e’ and LVMI increased in groups D and E,with statistically significant differences(P<0.05).3.Comparison of stratified strain parameters(expressed in absolute value)The absolute values of GLS and GCS in each layer showed a decreasing trend from the inner layer to the outer layer among the groups.Compared with the control group,GLS,GLSendo,GLSmid,GLSepi,GCS,GCSendo,GCSmid,GCSepi decreased in group E,with statistically significant differences(P<0.05).GLSendo decreased in group D,with statistically significant differences(P<0.05).4.ROC curve analysis of GLS and GCS in the evaluation of myocardial damage in subjects with different glomerular filtration rate,the analysis results showed that the area under the curve(AUC)of GLS was 0.753,and the area under the curve of GCS was 0.469.GLS had higher predictive accuracy than GCS.5.Using Pearson correlation analysis,the results showed that GLSendo,GLSmid,GLSepi were positively correlated with eGFR,and GLSendo was the most closely correlated with eGFR.Conclusions:1.The decline of cardiac diastolic function and ventricular deformation occur earlier than the change of ventricular systolic function.2.In patients with chronic kidney disease and eGFR <15ml/min,although LVEF was in the normal range,GLS,GLSendo,GLSmid,GLSepi,GCS,GCSendo,GCSmid,and GCSepi all decreased,but GLSendo decreased most obviously,suggesting that the subendocardial myocardium is more sensitive.3.In patients with chronic kidney disease and eGFR <30ml/min and LVEF in the normal range,GLSendo began to decrease when GCS did not change significantly,suggesting that GLS is more sensitive than GCS in the evaluation of myocardial injury in patients with chronic kidney disease.4.Layer-specific strain technique is more sensitive than conventional echocardiography in monitoring related myocardial injury in patients with chronic kidney disease.When the myocardial injury in patients with chronic kidney disease is in the subclinical stage,it is helpful to monitor the change of cardiac function,early detection and assist in clinical diagnosis and treatment.更多还原