nefrНефрологияNephrology (Saint-Petersburg)1561-62742541-9439Pavlov First Saint-Petersburg State Medical University10.24884/1561-6274-2007-11-4-47-54nefr-949Research ArticleОРИГИНАЛЬНЫЕ СТАТЬИ. КЛИНИЧЕСКИЕ ИССЛЕДОВАНИЯORIGINAL ARTICLES. CLINICAL INVESTIGATIONSАТЕРОСКЛЕРОЗ КАК ОСНОВНОЙ ФАКТОР КАЛЬЦИНОЗА КЛАПАННОГО АППАРАТА СЕРДЦА В ДОДИАЛИЗНОМ ПЕРИОДЕ ХРОНИЧЕСКОЙ БОЛЕЗНИ ПОЧЕКATHEROCLEROSIS AS THE MAIN FACTOR OF CALCINOSIS OF THE HEART VALVE APPARATUS IN THE PREDIALYSIS PERIOD OF CHRONIC KIDNEY DISEASEВолковМ. М.VolkovM. M.

Кафедра пропедевтики внутренних болезней, Научно-исследовательский  институт нефрологии

ДегтереваО. А.DegterevaO. A.

Кафедра пропедевтики внутренних болезней, Научно-исследовательский  институт нефрологии

СмирновА. В.SmirnovA. V.

Кафедра пропедевтики внутренних болезней, Научно-исследовательский  институт нефрологии

ШевяковаЕ. В.ShevyakovaE. V.

Кафедра пропедевтики внутренних болезней, Научно-исследовательский  институт нефрологии

ПанинаИ. Ю.PaninaI. Yu.

Кафедра пропедевтики внутренних болезней, Научно-исследовательский  институт нефрологии

ТрофименкоИ. И.TrofimenkoI. I.

Кафедра пропедевтики внутренних болезней, Научно-исследовательский  институт нефрологии

Санкт-Петербургский государствен­ный медицинский университет им. акад. И.П.ПавловаRussian Federation2007100420071144754Copyright © Волков М.М., Дегтерева О.А., Смирнов А.В., Шевякова Е.В., Панина И.Ю., Трофименко И.И., 20072007Волков М.М., Дегтерева О.А., Смирнов А.В., Шевякова Е.В., Панина И.Ю., Трофименко И.И.Volkov M.M., Degtereva O.A., Smirnov A.V., Shevyakova E.V., Panina I.Y., Trofimenko I.I.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/949

ЦЕЛЬ ИССЛЕДОВАНИЯ: определить частоту кальциноза митрального (МК) и аортального (АК) клапанов сердца у пациентов в додиализном периоде хронической болезни почек (ХБП) и установить факторы, с ним связанные. ПАЦИЕНТЫ И МЕТОДЫ. В исследование вошли 317 пациентов (46,1% мужчин и 53,9% женщин) с ХБП 1-5 стадий в додиализном периоде, в возрасте 50,7±15,2 лет (14-84). Пациенты с хроническим гломерулонефритом составляли 30,7%, с диабетической нефропатией 29,4%, с гипертонической болезнью 17,7%, с прочими заболеваниями - 22,0%. Пациентам выполняли доплер-эхокардиографию (доплер-ЭхоКГ), суточное мониторирование АД, ЭКГ. Состояние МК и АК оценивали как норму, уплотнение, кальциноз (фиброзного кольца или створок). Толщину комплекса интима-медия сонных артерий (КИМ) измеряли c двух сторон на 3 уровнях. У части пациентов определяли интактный паратгормон, выполняли денситометрию костей предплечья, рентгенологически определяли толщину кортикальных слоев 2-й пястной кости, измеряли суммарную протяженность кальциноза брюшной аорты по методике A.E. Hak и соавт. [1]. РЕЗУЛЬТАТЫ. Кальциноз клапанов в обследованной группе выявлен у 22,1% пациентов: АК – у 6,3%, МК – 4,1% и обоих клапанов у 11,7%. При сравнении групп, различающихся по наличию кальциноза клапанов (АК, МК или обоих), выявлено, что у пациентов с кальцинозом была больше толщина КИМ (p<0,001), старше возраст (p<0,001), чаще встречался сахарный диабет (p<0,001), ИБС (p<0,001), сердечная недостаточность (p<0,001), было выше АД (p<0,001), была ниже СКФ по формуле MDRD (p=0,033), меньше размеры почек (p=0,039) и толщина их паренхимы (p=0,015), отмечалась тенденция к более высоким значениям паратгормона (p=0,089). При использовании многофакторных методов (дискриминантного анализа) обнаружено, что на кальциноз клапанов независимо влияли толщина КИМ (p<0,001) и наличие сахарного диабета (р=0,024). ЗАКЛЮЧЕНИЕ. Кальциноз сердечных клапанов выявлен у 22,1% пациентов в додиализном периоде ХБП. Он тесно связан с атеросклерозом (в свою очередь ассоциированным с возрастом пациентов, гипертензией, снижением СКФ, воспалительными изменениями), а также с наличием сахарного диабета.

THE AIM of the investigation was to determine the incidence of calcinosis of the mitral (MV) and aortal (AV) heart valves in patients in the predialysis period of chronic kidney disease (CKD) and the associated factors. PATIENTS AND METHODS. The investigation included 317 patients (46.1% of men and 53.9% of women) with 1-5 stages of CKD in the predialysis period. The age of the patients was 50.7±15.2 years (14-84). There were 30.7% of patients with chronic glomerulonephritis, 29.4% with diabetic nephropathy, 17.7% with essential hypertension, 22.0% with other diseases. Doppleroechocardiography (Doppler-EchoCG), daily monitoring of AP, ECG were performed. The state of MV and AV was assessed: norm, hardening, calcinosis (of fibrous ring or cusps). The thickness of the carotid artery intima-media complex (IMC) was measured on two sides at 3 levels. In part of the patients the intact parathormone was determined, densitometry of the forearm bones was made, the thickness of cortical layers of the 2nd metacarpal bone was determined by X-ray examination, total extension of the abdominal aorta calcinosis was measured by the A.E.Hak el al. method. RESULTS. Valve calcinosis was detected in 22.1% of the first group patients: AV – in 6.3%, MV – in 4.1% and of the both valves in 11.7%. A comparison of the groups different in the presence of valve calcinosis (AV, MV or both) has shown that patients with calcinosis had greater thickness of IMC (p< 0.001), older age (p<0.001), more often incidence of diabetes mellitus (p<0.001), IHD (p<0.001), heart failure (p<0.001), higher AP (p<0.001), lower GFR by MDRD formula (p=0.033), less sizes of the kidneys (p=0.039) and their parenchyma thickness (p=0.015), tendency towards higher values of parathormone (p= 0.089). Using multifactor methods (discriminative analysis) revealed that valve calcinosis was independently influenced by IMC thichness (p=0.001) and diabetes mellitus (p=0.024). CONCLUSION. Heart valve calcinosis was revealed in 22.1% of the patients in the predialysis period of CKD. It was closely associated with atherosclerosis (in its turn associated with the patient’s age, hypertension, lower GFR, inflammatory alterations) and diabetes mellitus.

хроническая болезнь почекатеросклерозсердцеклапанный аппараткальцификацияchronic kidney diseaseatherosclerosisheartvalve apparatuscalcificationReferencesHak AE, Pols HA, van Hemert AM et al. Progression of aortic calcification is associated with metacarpal bone loss during menopause: a population-based longitudinal study. Arterioscler Thromb Vasc Biol 2000; 20(8): 1926-1931Hak AE, Pols HA, van Hemert AM et al. Progression of aortic calcification is associated with metacarpal bone loss during menopause: a population-based longitudinal study. Arterioscler Thromb Vasc Biol 2000; 20(8): 1926-1931Foley 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: 853-906U.S. Renal Data System, USRDS 2003 Annual Data Report: Atlas of End-Stage Renal Disease in the United States, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2003: 560U.S. Renal Data System, USRDS 2003 Annual Data Report: Atlas of End-Stage Renal Disease in the United States, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2003: 560Wang 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): 348-354Mazzaferro 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): 335-340Raj 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;103:98-102Bijak K, Matuszkiewicz-Rowinska J, Niemczyk S et al. Valvular and vascular calcifications in patients with chronic kidney disease: the role of dyslipidemia. Nephrol Dial Transpl 2006; 21 [suppl 4]: iv 404Bijak K, Matuszkiewicz-Rowinska J, Niemczyk S et al. Valvular and vascular calcifications in patients with chronic kidney disease: the role of dyslipidemia. Nephrol Dial Transpl 2006; 21 [suppl 4]: iv 404Волгина 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)Volgina G, Tomilina N, Lebedev S et al. Cardiac valve calcification in dialysis patients. Nephrol Dial Transpl 2006; 21 [suppl 4]: iv 405Volgina G, Tomilina N, Lebedev S et al. Cardiac valve calcification in dialysis patients. Nephrol Dial Transpl 2006; 21 [suppl 4]: iv 405Шило 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]: 58-66Rufino 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]:S115-118Raos 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):179-183Wang 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): 1927-1936Ribeiro 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): 2037-2040Levin A, Bakris GL, Molitch M et al. Prevalence of abnormal serum vitamin D, PTH, calcium, and phosphorus in patients with chronic kidney disease: results of the study to evaluate early kidney disease. Kid Int 2007; 71: 31-38Levin A, Bakris GL, Molitch M et al. Prevalence of abnormal serum vitamin D, PTH, calcium, and phosphorus in patients with chronic kidney disease: results of the study to evaluate early kidney disease. Kid Int 2007; 71: 31-38Jesri 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]Ix 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): 412-20Ix 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): 412-20Baglin 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): 521-526Otto CM, Lind BK, Kitzman DW et al. Association of aortic-valve sclerosis with cardiovascular mortality and morbidity in the elderly. N Engl J Med 1999; 341: 142–147Otto CM, Lind BK, Kitzman DW et al. Association of aortic-valve sclerosis with cardiovascular mortality and morbidity in the elderly. N Engl J Med 1999; 341: 142–147Moe SM, O’Neill KD, Duan D et al. Medial artery calcification in ESRD patients is associated with deposition of bone matrix proteins. Kidney Int 2002; 61: 638–647Moe SM, O’Neill KD, Duan D et al. Medial artery calcification in ESRD patients is associated with deposition of bone matrix proteins. Kidney Int 2002; 61: 638–647Mohler ER III, Gannon F, Reynolds C et al. Bone formation and inflammation in cardiac valves. Circulation 2001; 103: 1522–1528Mohler ER III, Gannon F, Reynolds C et al. Bone formation and inflammation in cardiac valves. Circulation 2001; 103: 1522–1528Raggi 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): 134-141Ventura 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): 1795-1801Huting 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): 383-388Malergue 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): 1595-1601Ferramosca E, Bellas A, Muntner P et al. Aortic valve calcification as a marker of coronary artery disease in prevalent hemodialysis patients. Nephrol Dial Transpl 2006; 21 [suppl 4]: iv 438Ferramosca E, Bellas A, Muntner P et al. Aortic valve calcification as a marker of coronary artery disease in prevalent hemodialysis patients. Nephrol Dial Transpl 2006; 21 [suppl 4]: iv 438Jeren-Strujic B, Raos V, Jeren T, Horvatin-Godler S. Comparative study of mitral annular calcification (MAC) with cardiac arrhythmias in dialysis patients. Coll Anthropol 1997; 21(1): 167-174Jeren-Strujic B, Raos V, Jeren T, Horvatin-Godler S. Comparative study of mitral annular calcification (MAC) with cardiac arrhythmias in dialysis patients. Coll Anthropol 1997; 21(1): 167-174

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