论文标题：Abdominal aortic calcification score as a predictor of clinical outcome in peritoneal dialysis patients: a prospective cohort study

期刊：BMC Nephrology

作者：Dahua Ma, Hao Yan et al.

发表时间：2020/04/30

DOI：10.1186/s12882-020-01822-9

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BMC Nephrolog 的博客编辑Daphne Harrington Knicely博士推荐了一篇由Ma和同事撰写的评价腹主动脉钙化评分（AACS）在腹膜透析（PD）患者中的预后价值，并讨论如何在该患者群中以最优的方式使用AACS的文章。

有心血管问题的终末期肾病患者比有同样问题的普通人群死亡率更高。在这个患者群体里，血管钙化导致的心血管疾病上升的风险和总死亡率的升高，很大程度上归因于矿物质骨疾病这一非传统危险因素。分析血液透析患者的多项研究表明，使用X光平片能有效地确定腹主动脉钙化和心血管疾病。Cho和同事最近发现，从 X射线计算机断层成像得到的腹主动脉钙化评分（AACS）是严重冠状动脉钙化的独立危险因素和血液透析患者患心血管疾病的预测因子。Zhu和同事发现，腹主动脉钙化在血液透析患者中很普遍，并且有可能通过X线平片来预测心血管疾病的死亡率。但是在腹膜透析（PD）患者中尚未进行过类似的研究。

Ma和同事于近期在BMC Nephrology 上发表的一项研究检验了AACS对PD患者的主要不良心血管事件（MACCE）和死亡率的预测作用。这项研究是一项单中心的前瞻性队列研究，利用腰椎侧位X线片来确定292例PD患者的AACS。研究发现，患者人群的中位PD持续时间为28.4个月，四分之一的患者有糖尿病史，三分之一的患者有心血管疾病史。平均AACS为2.0。研究人员将入组的患者分为三分位数：低（即AACS = 0），中（AACS = 1-4）和高（ACS> 4）。随访时间平均为43.6个月，有65例MACCE和84例死亡。值得注意的是，AACS与年龄、PD病程、心血管疾病和糖尿病相关。Ma和同事观察到，上三分位数的AACS中，MACCE的累积发生率和全因死亡率显著更高。

根据本研究和其他研究，我们是否应该常规地在终末期肾病患者（尤其是PD患者）中用X线平片获取腹主动脉钙化评分（AACS）？我会极力建议开始这一操作。X光是一种低成本、非侵入性的检查，可能有助于对风险进行分层化。AACS评分较高的患者应立即转诊至心脏病科，进行心血管疾病的预防和评估。测试的频率和测试的开始需要确定。另外，X线平片在肾移植评估中也有潜在用途。许多移植中心都在移植检查中采用平扫CT来决定缝合的部位。这些发现通常会导致进一步的心血管疾病方面的检测。这些CT结果可以分选出需要进行更多测试的人群。AACS评分较高的患者可能需要直接进行心脏导管检查以诊断和治疗心血管疾病。而AACS较低的患者可能会直接接受压力测试或冠状动脉CT。这种分层可以消除不必要的测试，防止并发症并节省成本。

另一种更为被动的情况，则是腹主动脉钙化被偶然验出。在这种情况下，患者可以去心脏科问诊或做进一步的检查。但是，在心血管疾病和死亡率高发的人群中，我认为需要主动出击，积极预防。

摘要：

Background

Abdominal aortic calcification assessed by X-ray is recommended to evaluate vascular calcification in dialysis patients. It has been shown that abdominal aortic calcification score (AACS) is a predictor of adverse outcomes in hemodialysis patients, but evidence regarding its prognostic value in peritoneal dialysis (PD) patients is still insufficient. We aimed to examine the predictive role of AACS for major adverse cardiac and cerebrovascular events (MACCE) and mortality in PD patients.

Methods

Eligible patients undergoing PD between July 2011 and July 2014 were recruited. AACS was quantified using lateral lumbar radiography at recruitment. Patients were prospectively followed up until death, PD cessation, or to the end of the study (August 31, 2018). Both subdistribution hazards and cause-specific hazards models were used to evaluate the association between AACS and MACCE as well as mortality.

Results

292 patients were enrolled, including 160 males (54.8%) with mean age 57.1 ± 15.2 years and median PD duration 28.4 (IQR 12.0, 57.8) months. Among them, 75 (25.7%) patients were comorbid with diabetes, and 94 (32.2%) patients had cardiovascular disease (CVD). The average AACS was 2.0 (0.0, 6.0). Patients were categorized on the tertiles of AACS (Low AACS group, AACS = 0, n = 125; Medium AACS group, AACS 1–4, n = 72; and High AACS group, AACS> 4, n = 95). AACS was associated with age (OR = 1.081, P < 0.001), PD duration (OR = 1.012, P = 0.003), CVD (OR = 1.919, P = 0.020) and diabetes (OR = 2.554, P = 0.002). During the follow-up period of 43.6 (24.6, 50.7) months, there were 65 MACCEs and 84 deaths. Significantly higher cumulative incidences of all-cause mortality (Log-rank = 35.992, P<0.001; Gray = 38.662, P < 0.001) and MACCE (Log-rank = 26.146, P<0.001; Gray = 27.810, P < 0.001) were observed in the upper AACS tertile. AACS was an independent predictor of all-cause mortality (HR = 2.438, 95% CI 1.246–4.772, P = 0.009; SHR = 2.323, 95%CI 1.229–4.389, P = 0.009) and MACCE (HR = 3.455, 95% CI 1.734–6.884, P < 0.001; SHR = 3.063, 95%CI 1.460–6.430, P = 0.003) in this study.

Conclusions

AACS was associated with age, PD duration, CVD and diabetes in PD patients. AACS could predict MACCE and all-cause mortality in this population. It thus might be a safe and feasible method to identify PD patients with adverse outcomes.

（来源：科学网）