「研究解读」延缓钙化进展或可降低死亡风险
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上世纪八十年代就有临床研究对终末期肾病(ESRD)患者中的血管钙化进行报导[1]。ESRD 及透析患者血管钙化的发生率是普通人群的 2-10 倍[1, 2]。因此,血管钙化对 ESRD 及透析患者的危害倍受关注。大量的临床研究已经证明,血管钙化与冠状动脉粥样硬化、血管壁僵硬、左心室肥大等心血管疾病相关[3-6]。KDIGO 指南指出,CKD-MBD 管理中应考虑患者血管钙化的情况[7],2013 年中国《慢性肾脏病矿物质和骨异常诊治指导》也建议每 6-12 个月进行一次心血管钙化评估[8]

 

过去研究发现血管钙化的程度越高,患者死亡风险越高[9-12],但均是基于患者基线时的血管钙化评分而进行的分析。那么,血管钙化进展是否会导致透析患者预后较差呢?2015 年法国学者 Jean G 等人在 Nephron 杂志上发表的一项临床研究为我们揭开了谜底[13]

 

该队列研究共纳入 85 例、平均年龄 70 岁、平均透析龄为 116 个月的血透患者,入组时进行血管钙化情况检测。由一名放射学家通过前骨盆、腰椎与膝盖轮廓、右手及右臂、胸、颅骨的X光片以及曲面体层片对患者的血管钙化程度进行评分(VC1)。三年后再次检测患者的血管钙化情况,并由同一名放射学家进行评分(VC2)。评分方法如下:无血管钙化记 0 分;主动脉或髂动脉轻度钙化记 1 分;主动脉 + 髂动脉 + 股动脉钙化记 2 分;包括主动脉、髂动脉、股动脉、腘动脉及手臂动脉在内的严重弥漫性血管钙化记 3 分。放射学家依据血管钙化评分的变化将患者分为钙化进展组(PG+, n=38)与钙化未进展组(PG-, n=47),继续随访三年,观察两组患者的生存率。

 

研究同时也计算了 Kauppila 评分。研究结果显示,从 VC2 的结果来看,92% 患者的血管钙化评分发生显著变化,PG- 组平均钙化评分为 1.48±0.9(平均 Kauppila 评分为 9.2±3),PG+ 组平均钙化评分为 2.5±0.6(平均 Kauppila 评分为 15.1±0.5)。经多因素校正后,同 PG- 组相比,PG+ 组患者的死亡风险明显上升(HR:2.7; 95% CI:1.12-6.6;P=0.02)。血管钙化发生进展与血透患者较差的预后显著相关,并且与患者的基线钙化评分无关。

 

该研究结果证实了,除血管钙化的程度外,血管钙化的进展也与透析患者的预后相关。过去发表的多项研究已经发现,使用非含钙磷结合剂如司维拉姆等可延缓透析患者的钙化进展[14-16],但延缓钙化进展是否可外推至临床硬终点的获益尚不清楚[7]。该研究的研究结果为临床通过延缓钙化进展改善预后提供了希望,然而该研究存在样本量较小,且未采用指南推荐的评分方法对受试者的血管钙化情况进行评分等局限性,未来仍需更多高质量的研究在这一方面进行探索。

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您在透析患者的治疗过程中对血管钙化检测的看法是?

A.血钙水平就能反映血管钙化的情况,无需进行其它检测
4%
B.仍需更多研究证实钙化检测对患者治疗的指导价值
50%
C.仅建议患者进行基线检测,以便于治疗用药的选择
4%
D.会建议患者进行定期检测
42%
总票数: 24
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