慢性腎衰竭病人腎功能與心肌梗塞指標之相關性探討

The relationship between markers of renal function and myocardial infarction in Chronic renal failure patients.

林怡如(Yi-Ju Lin)

指導教授 ： 曾博修

中山醫學大學/醫學院/生化暨生物科技研究所/碩士(2010年)

https://doi.org/10.6834/CSMU.2010.00152

摘要

背景：慢性腎臟疾病（chronic kidney disease, CKD）已被認定是心血管疾病（cardiovascular disease, CVD）的危險因子之一，一旦發生心血管疾病，慢性腎臟病患的死亡率也比一般人來的高。CKD 病程發展階段越接近後期，病患的腎功能越差，且罹患心血管疾病的危險性就越高，而長期進行血液透析治療的慢性腎衰竭病患主要的死亡原因是心肌梗塞。血液中的心肌梗塞生化指標，例如：Troponin-I或CK，在心肌發生輕微損害時即會上升，在慢性腎衰竭患者發生心肌梗塞時，以Troponin-I為最主要的心肌損傷生物標誌。有研究指出在較早期的腎功能衰竭時，以血清肌酸酐（serum creatinine）、尿素氮（blood urea nitrogen, BUN）及肌酸酐清除率（Creatinine clearance）作為衡量的指標，來預測冠狀動脈心臟病、急性心肌梗塞及罹患各種心血管疾病之患者的存活率。
方法：本研究將慢性腎衰竭之腎功能指標（BUN, Creatinine, GFR）、心肌梗塞指標（Troponin-I, CK）、發炎指標（hs-CRP）、受試者之年齡、性別以SPSS統計軟體來作分析統計，所使用之統計方法包含：信度分析、相關性、卡方檢定等分析方法，探討慢性腎衰竭患者腎功能指標與心肌梗塞指標之間的關聯性，以增加我們在臨床上對慢性腎衰竭患者發生急性心肌梗塞的生化指標做更進一步的了解。
結果：經皮爾森卡方檢定（Pearson chi-square）交叉分析結果發現，腎功能指標（BUN, Creatinine, GFR）與心肌梗塞指標（Troponin-I）具相關性（p＜ 0.05）。經Pearson相關分析結果發現，腎功能指標（BUN, Creatinine, GFR）與心肌梗塞指標（Troponin-I, CK）具有相關性（p＜ 0.01）。腎功能指標（BUN, Creatinine, GFR）與發炎指標（hs-CRP）也具有相關性（p＜ 0.01）。而Troponin-I,CK與 hs-CRP也具有相關性 （p＜ 0.01）。性別與年齡、腎功能指標（Creatinine）與心肌梗塞指標（Troponin-I）則不具相關性（p＞0.05）。
討論：因取樣之末期腎臟病患分期皆已達末期腎臟病變階段（第五期，GFR約為<15 ml/min/1.73 m2）或已接受透析治療，在末期腎臟疾病較早分期（第一期至第四期，GFR為15-100 ml/min/1.73 m2）病患中，其GFR與心肌梗塞指標之間的關聯性，仍待進一步的研究分析。本研究中Troponin-I的cut-off訂定為0.4 ng/mL，收集之末期腎臟病患之Troponin-I檢驗數值平均為1.28 ng/mL，creatinine平均為4.6 mg/dl，經統計病患之腎功能指標（BUN, Creatinine, GFR）與心肌梗塞指標具有相關性，但腎功能指標及心肌梗塞指標與急性心肌梗塞死亡率之間的關係，以及用來早期篩檢末期腎臟病患急性心肌梗塞的Troponin-I cut-off值，仍待進一步的研究及確認。本研究中末期腎臟病患hs-CRP平均為6.46 mg/dL，顯示病患普遍皆有發炎反應發生，經統計結果顯示hs-CRP與心肌梗塞指標及腎功能指標皆具相關性，然而因hs-CRP是非特異性的發炎指標，可能受到感染或其他因素影響，所以其間複雜的機制，更待進一步研究。

關鍵字

急性心肌梗塞 ； 冠狀動脈心臟病 ； 腎小球濾過率 ； 慢性腎臟疾病

並列摘要

Background: Chronic kidney disease, CKD has been considered one of the factors of cardiovascular disease, CVD. Once the patients who have cardiovascular disease, CVD, the mortality of patients who have chronic kidney disease, CKD is higher than ordinaries. When the level of progress development approaches the later stage, the patients’ kidney functions are going to get worse. Moreover, the probability that patients who have chronic kidney disease, CKD of having cardiovascular disease, CVD is higher. The major cause of death of the end stage renal disease who is under the long-term hemodialysis treatment is myocardial infarction. The myocardial infarction markers in serum; for example, Troponin-I or CK increase when the myocardium damage. Troponin-I is the most significant index for the myocardial infarction markers when the patients of chronic kidney disease, CKD who are affected with myocardial infarction. Several researches have indicated that in the early stages of renal failure ,serum creatinine, blood urea nitrogen, BUN and creatinine clearance are used evaluating and predicting the survival rate of coronary artery disease, acute myocardial infarction and any kinds of cardiovascular diseases.
Method: The study analyses the BUN, Creatinine, GFR, Troponin-I, CK, hs-CRP, the age and sex of the subject by using SPSS statistical software. The statistical methods include reliability analysis, correlation, chi square test, linear regression analysis. We can know the relationship between BUN, Creatinine, GFR and Troponin-I, CK by using this method. We can have further understanding of the changes of Troponin-I, CK when the patients who have chronic kidney desease, CKD are affected with acute myocardial infarction.
Results: Use the Pearson chi-square test cross-analysis found that renal function markers (BUN, Creatinine, GFR) and myocardial infarction markers (Troponin-I) are correlated (p <0.05). Use the Pearson correlation analysis found that renal function markers (BUN, Creatinine, GFR) and myocardial infarction markers (Troponin-I, CK) are correlated (p <0.01). Renal function markers (BUN, Creatinine, GFR) and inflammation markers (hs-CRP) are correlated (p <0.01). Troponin-I, CK and hs-CRP also correlated (p <0.01). The sex with the age, kidney function marker (Creatinine) and myocardial infarction marker (Troponin-I) is not a correlation (p> 0.05).
Discussion: The samples of patients of the end-stage renal disease reached the end of the stage of the nephropathy( Level Five, GFR is approximately < 15 ml/min/1.73 m2) or had been under the treatment of hemodialysis. The relation between GFR and Troponin-I, CK has not been found in the patients of the early stage of the end- stage renal disease(Level One to Four, GFR is 15-100 ml/min/1.73 m2). The value for cut-off in Troponin-I is 0.4 ng/ml. The mean of the examiner data of Troponin-I is 1.1613 ng/ml and the mean of the examiner data of Creatinine is 4.9 mg/dl. There are some relation between BUN, Creatinine, GFR and Troponin-I in this result. However, the cut-off value of Troponin-I still need more experiments and examinations to evaluate the accuracy of the cut-off value. The average of hs-CRP that the patients of the end-stage renal disease are 6.46 mg.dL indicated that all the patients had the reaction of inflammation. The statistics showed that there are relation between BUN,Creatinine, GFR and Troponin-I. Nevertheless, hs-CRP is non-specific index for the inflammation because it might be affected or be infected by other factors. As a result, the relation between those factors needs more tests and examinations to prove it.

並列關鍵字

Acute Myocardial Infarction ； coronary artery disease ； Creatine Kinase ； Troponin-I ； glomerular filration rate ； chronic kidney disease

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