nefrНефрологияNephrology (Saint-Petersburg)1561-62742541-9439Pavlov First Saint-Petersburg State Medical University10.24884/1561-6274-2008-12-1-46-52nefr-1013Research ArticleОРИГИНАЛЬНЫЕ СТАТЬИ. КЛИНИЧЕСКИЕ ИССЛЕДОВАНИЯORIGINAL ARTICLES. CLINICAL INVESTIGATIONSКАЛЬЦИНОЗ КЛАПАННОГО АППАРАТА СЕРДЦА И СОСТОЯНИЕ МИОКАРДА У ПАЦИЕНТОВ В ДОДИАЛИЗНОМ ПЕРИОДЕ ХРОНИЧЕСКОЙ БОЛЕЗНИ ПОЧЕКCARDIAC VALVULAR CALCIFICATION AND STATE OF THE MYOCARDIUM IN PATIENTS IN THE PREDIALYSIS PERIOD OF CHRONIC KIDNEY DISEASEВолковМ. М.VolkovM. M.

кафедра пропедевтики внутренних болезней

СмирновА. В.SmirnovA. V.

кафедра пропедевтики внутренних болезней

ДегтереваО. А.DegterevaO. A.

кафедра пропедевтики внутренних болезней

ШевяковаЕ. В.ShevyakovaE. V.

кафедра пропедевтики внутренних болезней

ТрофименкоИ. И.TrofimenkoI. I.

кафедра пропедевтики внутренних болезней

ПанинаИ. Ю.PaninaU. Ya.

кафедра пропедевтики внутренних болезней

Научно-исследовательский институт нефрологии Санкт-Петербургского государствен­ного медицинского университета им. акад. И.П. ПавловаRussian Federation2008100120081214652Copyright © Волков М.М., Смирнов А.В., Дегтерева О.А., Шевякова Е.В., Трофименко И.И., Панина И.Ю., 20082008Волков М.М., Смирнов А.В., Дегтерева О.А., Шевякова Е.В., Трофименко И.И., Панина И.Ю.Volkov M.M., Smirnov A.V., Degtereva O.A., Shevyakova E.V., Trofimenko I.I., Panina U.Y.Данная работа распространяется под лицензией Creative Commons Attribution 4.0.This work is licensed under a Creative Commons Attribution 4.0 License.https://journal.nephrolog.ru/jour/article/view/1013

ЦЕЛЬ ИССЛЕДОВАНИЯ: определить характер связи между кальцинозом митрального (МК) и аортального (АК) клапанов сердца и состоянием миокарда у пациентов в додиализном периоде хронической болезни почек (ХБП). ПАЦИЕНТЫ И МЕТОДЫ. В исследование были включены 317 пациентов в додиализном периоде с ХБП 1-5 стадий, 46,1% мужчин и 53,9%  женщин, среднего возраста 50,7±15,2 лет с выполненной доплер-эхокардиографией. Пациенты с хроническим гломерулонефритом составляли 30,7%, с диабетической нефропатией 29,4%, с гипертонической болезнью 17,7%, с прочими заболеваниями - 22,0%.  РЕЗУЛЬТАТЫ ИССЛЕДОВАНИЯ. Кальциноз сердечных клапанов в обследованной группе выявлен у 22,1% пациентов: АК - у 6,3%, МК - 4,1% и обоих клапанов у 11,7%. При кальцинозе АК и МК чаще отмечался их стеноз (p<0,001 и p=0,002 соответственно) и приклапанная регургитация 1-й и выше степени (p=0,002 и p=0,053). В группе пациентов с наличием кальциноза АК или МК были больше диаметр аорты (p=0,005), левого (p<0,001) и правого предсердий (p<0,001),  правого желудочка (p=0,007), толщина стенок правого (p<0,001) и левого желудочков (p<0,001), больше диаметр и давление в легочной артерии (p<0,001), более выражена диастолическая дисфункция по показателю Е/А (p<0,001), больше градиенты давления на МК (p<0,001) и АК (p<0,001) и потоки через МК (p<0,001) и АК (p<0,001). По данным многофакторного анализа с кальцинозом клапанов связаны следующие независимые факторы: диаметр предсердий (p<0,001), максимальные градиенты давления на АК (p<0,001), МК (p<0,001), показатель E/A (p<0,001), степень аортальной регургитации (p=0,004), диаметр ЛА (p=0,041). ЗАКЛЮЧЕНИЕ. Кальциноз МК и АК независимо от других факторов приводит к стенозу и недостаточности клапанов, повышению максимальных градиентов и максимальных потоков на АК, МК, дилатации предсердий, ЛА, диастолической дисфункции.

THE AIM of the investigation was to determine the character of relationship between mitral valve (MV) calcification and aortal valve (AV) calcification and the state of myocardium in patients in the predialysis period of chronic kidney disease (CKD). PATIENTS AND METHODS. The investigation included 317 patients in the predialysis period with CKD of the I-V stages, 46.1% of men and 53.9% of women, mean age 50.7±15.2 years with Doppler-echocardiography performed. Patients with chronic glomerulonephritis made up 30.7%, with diabetic nephropathy - 29.4%, with essential hypertension -17.7%, with other diseases -22.0%. RESULTS. Cardiac valvular calcification was revealed in 22.1% of the examined patients: AV - in 6.3%, MV - 4.1% and of both valves in 11.7%. In calcification of AV and MV their stenosis was noted more often (p<0.001 and p= 0.002 respectively) as well as perivalvular regurgitation of the1 degree and higher (p=0.002 and p=0.053). Patients with calcification of AV and  MV had greater diameter of the aorta (p=0.005), left (p<0.001) and right atriums (p<0.001), right ventricle (p=0.007), thickness of walls of the right (p<0.001) and left (p<0.001) ventricles, greater diameter and pressure in the pulmonary artery (p<0.001), more pronounced diastolic dysfunction by the E/A index (p<0.001), higher pressure gradients on MV (p<0.001) and AV (p<0.001) and flows through MV (p<0.001) and AV (p<0.001). By the data of multifactor analysis the following independent factors are associated with valvular calcification:  diameter of the atriums (p<0.001), maximum gradient of pressure on AV (p<0.001), MV (p<0.001), the E/A index (p<0.001), the aortal regurgitation degree (p=0.004), LA diameter (p=0.041). CONCLUSION. MV and AV calcification, irrespective of other factors, results in insufficiency of the valves, increased maximum gradients and maximum flows on AV and MV, dilatation of the atriums, LA, diastolic dysfunction.

кальциноз митрального и аортального клапановхроническая болезнь почекдодиализный периоддоплер-эхокардиографиядиастолическая дисфункциядилатация предсердийгипертрофия левого желудочкаcalcification of the mitral and aortal valveschronic kidney diseasepredialysis periodDoppler-echocardiographydiastolic dysfunctionatrium dilatationhypertrophy of the left ventricleReferencesGo AS, Chertow GM, Fan D et al. Chronic kidney disease and the risks of death, cardiovascular events, and hospitalization. N Engl J Med 2004; 351(13): 1296-1305Go AS, Chertow GM, Fan D et al. Chronic kidney disease and the risks of death, cardiovascular events, and hospitalization. N Engl J Med 2004; 351(13): 1296-1305Foley RN, Parfrey PS, Harnett JD et al. Clinical and echocardiographic disease in end-stage renal disease: prevalence, associations and prognosis. Kidney Int 1995; 47: 186-192Foley RN, Parfrey PS, Harnett JD et al. Clinical and echocardiographic disease in end-stage renal disease: prevalence, associations and prognosis. Kidney Int 1995; 47: 186-192Levey AS, Beto JA, Coronado BE et al. Controlling the epidemic of cardiovascular disease in chronic renal disease: What do we know? What do we need to learn? Where do we go from here? Am J Kid Dis 1998; 32: 853-906Levey AS, Beto JA, Coronado BE et al. Controlling the epidemic of cardiovascular disease in chronic renal disease: What do we know? What do we need to learn? Where do we go from here? Am J Kid Dis 1998; 32: 853-906Mazzaferro S., Coen G, Bandini S et al. Role of ageing, chronic renal failure and dialysis in the calcification of mitral annulus. Nephrol Dial Transplant 1993; 8(4): 335-340Mazzaferro S., Coen G, Bandini S et al. Role of ageing, chronic renal failure and dialysis in the calcification of mitral annulus. Nephrol Dial Transplant 1993; 8(4): 335-340Huting J. Predictive value of mitral and aortic valve sclerosis for survival in end-stage renal disease on continuous ambulatory peritoneal dialysis. Nephron 1993; 64(1): 63-68Huting J. Predictive value of mitral and aortic valve sclerosis for survival in end-stage renal disease on continuous ambulatory peritoneal dialysis. Nephron 1993; 64(1): 63-68Kushiya F, Wada H, Sakakura M et al. Prognostic impact of aortic calcification index and ankle-arm blood pressure index in patients under hemodialysis. Clin Appl Thromb Hemost 2005; 11(2): 161-169Kushiya F, Wada H, Sakakura M et al. Prognostic impact of aortic calcification index and ankle-arm blood pressure index in patients under hemodialysis. Clin Appl Thromb Hemost 2005; 11(2): 161-169Baglin A, Hanslik Т, Vaillant J et al. Severe valvular heart disease in patients on chronic dialysis. A five-year multicenter French survey. Ann Med Interne Paris 1997; 148(8): 521-526Baglin A, Hanslik Т, Vaillant J et al. Severe valvular heart disease in patients on chronic dialysis. A five-year multicenter French survey. Ann Med Interne Paris 1997; 148(8): 521-526Wang AY, Wang M, Woo J et al. Cardiac valve calcification as an important predictor for all-cause mortality and cardiovascular mortality in long-term peritoneal dialysis patients: a prospective study. J Am Soc Nephrol 2003; 14(1): 159-168Wang AY, Wang M, Woo J et al. Cardiac valve calcification as an important predictor for all-cause mortality and cardiovascular mortality in long-term peritoneal dialysis patients: a prospective study. J Am Soc Nephrol 2003; 14(1): 159-168Sharma R, Pellerin D, Gaze DC et al. Mitral annular calcification predicts mortality and coronary artery disease in end stage renal disease. Atherosclerosis 2007; 191(2): 348-354Sharma R, Pellerin D, Gaze DC et al. Mitral annular calcification predicts mortality and coronary artery disease in end stage renal disease. Atherosclerosis 2007; 191(2): 348-354Шило ВЮ, Гендлин ГЕ, Перекокин ЮН и др. Кальциноз структур сердца у больных на программном гемодиализе: связь с факторами риска и показателями внутрисердечной гемодинамики. Нефрология и диализ 2003; 5(1) [приложение 1]: 58-66Шило ВЮ, Гендлин ГЕ, Перекокин ЮН и др. Кальциноз структур сердца у больных на программном гемодиализе: связь с факторами риска и показателями внутрисердечной гемодинамики. Нефрология и диализ 2003; 5(1) [приложение 1]: 58-66Huting J. Mitral valve calcification as an index of left ventricular dysfunction in patients with end-stage renal disease on peritoneal dialysis. Chest 1994; 105(2): 383-388Huting J. Mitral valve calcification as an index of left ventricular dysfunction in patients with end-stage renal disease on peritoneal dialysis. Chest 1994; 105(2): 383-388Ventura JE, Tavella N, Romero C et al. Aortic valve calcification is an independent factor of left ventricular hypertrophy in patients on maintenance haemodialysis. Nephrol Dial Transplant 2002; 17(10): 1795-1801Ventura JE, Tavella N, Romero C et al. Aortic valve calcification is an independent factor of left ventricular hypertrophy in patients on maintenance haemodialysis. Nephrol Dial Transplant 2002; 17(10): 1795-1801Movahed MR, Saito Y, Ahmadi-Kashani M, Ebrahimi R. Mitral annulus calcification is associated with valvular and cardiac structural abnormalities. Ultrasound 2007; 5: 14Movahed MR, Saito Y, Ahmadi-Kashani M, Ebrahimi R. Mitral annulus calcification is associated with valvular and cardiac structural abnormalities. Ultrasound 2007; 5: 14Devereux RB, Alonso DR, Lutas EM et al. Echocardiographic assessment of left ventricular hypertrophy: comparison to necropsy findings. Am J Cardiol 1986; 57(6): 450-458Devereux RB, Alonso DR, Lutas EM et al. Echocardiographic assessment of left ventricular hypertrophy: comparison to necropsy findings. Am J Cardiol 1986; 57(6): 450-458Raj Dominic SC, Somiah S, Mani K et al. Valvular dysfunction in uraemia. Indian J Med Res 1996; 103: 98-102Raj Dominic SC, Somiah S, Mani K et al. Valvular dysfunction in uraemia. Indian J Med Res 1996; 103: 98-102Volgina G, Tomilina N, Lebedev S et al. Cardiac valve calcification in dialysis patients. Nephrol Dial Transplant 2006; 21 [suppl 4]: iv 405Volgina G, Tomilina N, Lebedev S et al. Cardiac valve calcification in dialysis patients. Nephrol Dial Transplant 2006; 21 [suppl 4]: iv 405Rufino M, Garcia S, Jimenez A et al. Heart valve calcification and calcium x phosphorus product in hemodialysis patients: analysis of optimum values for its prevention. Kidney Int 2003; 85 [Suppl]: S115-118Rufino M, Garcia S, Jimenez A et al. Heart valve calcification and calcium x phosphorus product in hemodialysis patients: analysis of optimum values for its prevention. Kidney Int 2003; 85 [Suppl]: S115-118Raggi P, Bommer J, Chertow GM. Valvular calcification in hemodialysis patients randomized to calcium-based phosphorus binders or sevelamer. J Heart Valve Dis 2004; 13(1): 134-141Raggi P, Bommer J, Chertow GM. Valvular calcification in hemodialysis patients randomized to calcium-based phosphorus binders or sevelamer. J Heart Valve Dis 2004; 13(1): 134-141Волков ММ, Дегтерева ОА, Смирнов АВ и др. Атеросклероз как основной фактор кальциноза клапанного аппарата сердца в додиализном периоде хронической болезни почек. Нефрология 2007; 11(4): 47-54.Волков ММ, Дегтерева ОА, Смирнов АВ и др. Атеросклероз как основной фактор кальциноза клапанного аппарата сердца в додиализном периоде хронической болезни почек. Нефрология 2007; 11(4): 47-54.Волгина ГВ, Перепеченых ЮВ, Бикбов БТ. Кальцификация клапанов сердца у больных с терминальной хронической почечной недостаточностью. Нефрология и диализ 2001; 3(1)Волгина ГВ, Перепеченых ЮВ, Бикбов БТ. Кальцификация клапанов сердца у больных с терминальной хронической почечной недостаточностью. Нефрология и диализ 2001; 3(1)Wang AY, Ho SS, Wang M et al. Cardiac valvular calcification as a marker of atherosclerosis and arterial calcification in end-stage renal disease. Arch Intern Med 2005; 165(3): 327-332Wang AY, Ho SS, Wang M et al. Cardiac valvular calcification as a marker of atherosclerosis and arterial calcification in end-stage renal disease. Arch Intern Med 2005; 165(3): 327-332Перекокин ЮН, Шило ВЮ, Гендлин ГЕ и др. Скорость пульсовой волны и податливость аорты у больных на программном гемодиализе: связь с факторами риска, кальцинозом сердца и показателями внутрисердечной гемодинамики. Нефрология и диализ 2004; 6(1): 62-69Перекокин ЮН, Шило ВЮ, Гендлин ГЕ и др. Скорость пульсовой волны и податливость аорты у больных на программном гемодиализе: связь с факторами риска, кальцинозом сердца и показателями внутрисердечной гемодинамики. Нефрология и диализ 2004; 6(1): 62-69Ribeiro S, Ramos A, Brandao A et al. Cardiac valve calcification in haemodialysis patients: role of calcium-phosphate metabolism. Nephrol Dial Transplant 1998; 13(8): 2037-2040Ribeiro S, Ramos A, Brandao A et al. Cardiac valve calcification in haemodialysis patients: role of calcium-phosphate metabolism. Nephrol Dial Transplant 1998; 13(8): 2037-2040Wang AY, Woo J, Wang M et al. Association of inflammation and malnutrition with cardiac valve calcification in continuous ambulatory peritoneal dialysis patients. J Am Soc Nephrol 2001; 12(9): 1927-1936Wang AY, Woo J, Wang M et al. Association of inflammation and malnutrition with cardiac valve calcification in continuous ambulatory peritoneal dialysis patients. J Am Soc Nephrol 2001; 12(9): 1927-1936Raos V, Jeren-Strujic B, Antos M, Horvatin-Godler S. Frequency of mitral annular calcification in patients on hemodialysis estimated by 2-dimensional echocardiography. Acta Med Croatica 1996; 50(4-5): 179-183Raos V, Jeren-Strujic B, Antos M, Horvatin-Godler S. Frequency of mitral annular calcification in patients on hemodialysis estimated by 2-dimensional echocardiography. Acta Med Croatica 1996; 50(4-5): 179-183Malergue MC, Urena P, Prieur P et al. Incidence and development of aortic stenosis in chronic hemodialysis. An ultrasonographic and biological study of 112 patients. Arch Mal Coeur Vaiss 1997; 90(12): 1595-1601Malergue MC, Urena P, Prieur P et al. Incidence and development of aortic stenosis in chronic hemodialysis. An ultrasonographic and biological study of 112 patients. Arch Mal Coeur Vaiss 1997; 90(12): 1595-1601Ix JH, Shlipak MG, Katz R et al. Kidney function and aortic valve and mitral annular calcification in the Multi-Ethnic Study of Atherosclerosis (MESA). Am J Kidney Dis 2007; 50(3): 412-420Ix JH, Shlipak MG, Katz R et al. Kidney function and aortic valve and mitral annular calcification in the Multi-Ethnic Study of Atherosclerosis (MESA). Am J Kidney Dis 2007; 50(3): 412-420Jesri A, Braitman LE, Pressman GS. Severe mitral annular calcification predicts chronic kidney disease. Int J Cardiol 2007 Jul 19; [Epub ahead of print]Jesri A, Braitman LE, Pressman GS. Severe mitral annular calcification predicts chronic kidney disease. Int J Cardiol 2007 Jul 19; [Epub ahead of print]Linhartova K, Veselka J, Sterbakova G et al. Parathyroid hormone and vitamin D levels are independently associated with calcific aortic stenosis. Circ J 2008; 72(2): 245-250Linhartova K, Veselka J, Sterbakova G et al. Parathyroid hormone and vitamin D levels are independently associated with calcific aortic stenosis. Circ J 2008; 72(2): 245-250Resnick LM, Muller FB, Laragh JH. Calcium-regulating hormones in essential hypertension. Relation to plasma renin activity and sodium metabolism. Ann Intern Med 1986; 105(5): 649-654Resnick LM, Muller FB, Laragh JH. Calcium-regulating hormones in essential hypertension. Relation to plasma renin activity and sodium metabolism. Ann Intern Med 1986; 105(5): 649-654Burgess ED, Hawkins RG, Watanabe M. Interaction of 1,25-dihydroxyvitamin D and plasma renin activity in high renin essential hypertension. Am J Hypertens 1990; 3(12 Pt 1): 903-905Burgess ED, Hawkins RG, Watanabe M. Interaction of 1,25-dihydroxyvitamin D and plasma renin activity in high renin essential hypertension. Am J Hypertens 1990; 3(12 Pt 1): 903-905Kristal-Bohen E, Froom P, Harari G et al. Association of calcitriol and blood pressure in normotensive men. Hypertension 1997; 30: 1289-1294Kristal-Bohen E, Froom P, Harari G et al. Association of calcitriol and blood pressure in normotensive men. Hypertension 1997; 30: 1289-1294Lind L, Hanni A, Lithell H et al. Vitamin D is related to blood pressure and other cardiovascular risk factors in middle-aged men. Am J Hypertens 1995; 8(9): 894-901Lind L, Hanni A, Lithell H et al. Vitamin D is related to blood pressure and other cardiovascular risk factors in middle-aged men. Am J Hypertens 1995; 8(9): 894-901Watson KE, Abrolat ML, Malone LL et al. Active serum vitamin D levels are inversely correlated with coronary calcification. Circulation 1997 16; 96(6): 1755-1760Watson KE, Abrolat ML, Malone LL et al. Active serum vitamin D levels are inversely correlated with coronary calcification. Circulation 1997 16; 96(6): 1755-1760Park CW, Oh YS, Shin YS et al. Intravenous calcitriol regresses myocardial hypertrophy in hemodialysis patients with secondary hyperparathyroidism. Am J Kidney Dis 1999; 33(1): 73-81Park CW, Oh YS, Shin YS et al. Intravenous calcitriol regresses myocardial hypertrophy in hemodialysis patients with secondary hyperparathyroidism. Am J Kidney Dis 1999; 33(1): 73-81Zittermann A, Schleithoff SS, Tenderich G et al. Low vitamin D status: a contributing factor in the pathogenesis of congestive heart failure? J Am Coll Cardiol 2003 1; 41(1): 105-112Zittermann A, Schleithoff SS, Tenderich G et al. Low vitamin D status: a contributing factor in the pathogenesis of congestive heart failure? J Am Coll Cardiol 2003 1; 41(1): 105-112Teng M, Wolf M, Ofsthun MN et al. Activated injectable vitamin D and hemodialysis survival: a historical cohort study. J Am Soc Nephrol 2005; 16(4): 1115-1125Teng M, Wolf M, Ofsthun MN et al. Activated injectable vitamin D and hemodialysis survival: a historical cohort study. J Am Soc Nephrol 2005; 16(4): 1115-1125Shoji T, Shinohara K, Kimoto E et al. Lower risk for cardiovascular mortality in oral 1alpha-hydroxy vitamin D3 users in a haemodialysis population. Nephrol Dial Transplant 2004; 19(1): 179-84Shoji T, Shinohara K, Kimoto E et al. Lower risk for cardiovascular mortality in oral 1alpha-hydroxy vitamin D3 users in a haemodialysis population. Nephrol Dial Transplant 2004; 19(1): 179-84

The authors declare that there are no conflicts of interest present.