慢性肾脏病心力衰竭患者的管理与预后：来自一家跨学科诊所的经验
Management and outcomes of heart failure patients with CKD: experience from an inter-disciplinary clinic.
作者信息
Nguyen Mai, Rumjaun Samir, Lowe-Jones Racquel, Ster Irina Chis, Rosano Giuseppe, Anderson Lisa, Banerjee Debasish
机构信息
Renal and Transplantation Unit, St George's University Hospital NHS Foundation Trust, London, UK.
Cardiology Clinical Academic Group, Molecular and Clinical Sciences Research Institute, St George's, University of London, St George's Hospital, Grosvenor Wing Room 2.113, Blackshaw Road, Tooting, London, SW170QT, UK.
出版信息
ESC Heart Fail. 2020 Oct;7(5):3225-3230. doi: 10.1002/ehf2.12796. Epub 2020 Jul 11.
AIMS
CKD-HF patients suffer excess hospitalization and mortality, often under-treated with life-prolonging medications due to fear of worsening renal function and hyperkalaemia. Yet, role of inter-disciplinary working in improving therapy is unknown, which this study aims to investigate.
METHODS AND RESULTS
Clinical, biochemical data, and medications at first and last clinic visit were obtained from patient records for 124 patients seen in kidney failure-heart failure clinic (23 March 2017 to 11 April 2019). Medication dose groups (none, low, and high dose), number of RAASi agents, and blood test results were compared between first and last visit in patients with at least two clinic visits (n = 97). Patient characteristics were age 78.5 years (IQR 68.1-84.4 years), male 67.7%, diabetes 51.6%, moderate (45.2%) vs. severe (39.5%) CKD, HF with reduced ejection fraction (HFrEF) (49.2%), follow-up 234 days (IQR 121-441 days). HFrEF was associated with increased risk of death (adjusted OR 4.49, 95% CI 1.43-14.05; P = 0.01). Distributions of patients according to number of RAASi agents they were on differed between first and last visit (P = 0.03). Dosage was increased in 25.9% for beta-blockers, 33.0% for ACEi/ARBs, and 17.5% for MRAs. Distributions of patients across MRA dosage groups was different (P = 0.03), with higher proportions on higher dosages at last visit, without significant changes in serum potassium or creatinine. Serum ferritin improved (131.0 vs. 267.5 μg/L; P < 0.001), and fewer patients had iron deficiency (56.7% vs. 26.8%; P = 0.002) at last visit compared to the first.
CONCLUSIONS
This inter-disciplinary clinic improved guideline-recommended medication prescription, MRA dosages in CKD-HF patients without significant biochemical abnormality, and iron status. A prospectively designed study with medication titration protocol and defined patient-centred outcomes is needed to further assess effectiveness of such clinic.
目的
慢性肾脏病合并心力衰竭（CKD-HF）患者住院率和死亡率过高，由于担心肾功能恶化和高钾血症，他们往往未充分接受延长生命的药物治疗。然而，多学科协作在改善治疗方面的作用尚不清楚，本研究旨在对此进行调查。
方法与结果
从2017年3月23日至2019年4月11日在肾衰竭-心力衰竭门诊就诊的124例患者的病历中获取首次和末次门诊就诊时的临床、生化数据及用药情况。对至少就诊两次的患者（n = 97），比较首次和末次就诊时的药物剂量组（无、低剂量和高剂量）、肾素-血管紧张素-醛固酮系统抑制剂（RAASi）药物数量及血液检查结果。患者特征为年龄78.5岁（四分位间距68.1 - 84.4岁），男性占67.7%，糖尿病占51.6%，中度CKD占45.2%，重度CKD占39.5%，射血分数降低的心力衰竭（HFrEF）占49.2%，随访234天（四分位间距121 - 441天）。HFrEF与死亡风险增加相关（校正比值比4.49，95%置信区间1.43 - 14.05；P = 0.01）。首次和末次就诊时，患者所使用RAASi药物数量的分布存在差异（P = 0.03）。β受体阻滞剂剂量增加的患者占25.9%，血管紧张素转换酶抑制剂/血管紧张素Ⅱ受体拮抗剂（ACEi/ARBs）剂量增加的患者占33.0%，醛固酮受体拮抗剂（MRAs）剂量增加的患者占17.5%。不同MRA剂量组患者的分布不同（P = 0.03），末次就诊时高剂量组的患者比例更高，血清钾或肌酐无显著变化。血清铁蛋白水平有所改善（131.0 μg/L对267.5 μg/L；P < 0.001），与首次就诊相比，末次就诊时缺铁患者减少（56.7%对26.8%；P = 0.002）。
结论
该多学科门诊改善了指南推荐药物的处方、CKD-HF患者的MRA剂量，且无显著生化异常，并改善了铁状态。需要进行一项前瞻性设计的研究，采用药物滴定方案并确定以患者为中心的结局，以进一步评估此类门诊的有效性。
Zotero 插件