혈액투석 환자에서 혈관내피세포 기능이상과관련된 인자들에 관한 연구 = Factors associated with Endothelial Dysfunctionin Hemodialysis Patients

다국어 초록 (Multilingual Abstract)

Purpose : Endothelial dysfunction is an event in the atherosclerotic process usually considered reversible at its early stage. Early detection, therefor, may improve the prognosis in the cardiovascular disease. The aim of this study was to investigate the vascular function in hemodialysis (HD) patients and to explore its relation to other various parameters with a specific emphasis on systemic inflammatory reaction (SIR), nutritional status and the presence of ischemic heart disease (IHD).
Methods : Flow-mediated endothelium-dependent vasodilatation (FMD) was measured, using Doppler sonogram, in 37 stable HD patients, 11 healthy people and 24 hypertensive controls. Nitroglycerine- induced endothelium-independent vasodilatation (EIV) and peak reaction time (PT) of each FMD and EIV were also measured.
Results : FMD in HD patients was decreased compared to healthy group whereas it was comparable in HD patients and hypertensive control. EIV in HD patients was significantly decreased compared to healthy and hypertensive controls. PT of each FMD and EIV was significantly delayed in HD patients. Each FMD and EIV showed a negative correlation with serum hsCRP level, but no significant correlations of FMD with other parameters were noted. Both FMD and EIV were further decreased in HD patients with IHD than non-IHD group.
Conclusion : Our study confirmed a characteristic pattern of vascular dysfunction in HD patients: the impaired endothelial and smooth muscle function with a delayed reaction time. Importantly, SIR was one of the important factors determining vascular dysfunction in HD patients. Further studies will be necessary to define the causative role of SIR on endothelial dysfunction and the effect of inflammation- modulating therapy.

국문 초록 (Abstract)

목 적 : 동맥경화성 심혈관계 질환은 아직도 투석 환자에서 사망의 가장 흔한 원인이다. 혈관내피세포의 기능이상은 동맥경화증 발생의 가장 초기 단계에 발생하는 중요한 과정으로, 비가역적인 변화인 동맥경화증과는 달리 회복 가능한 가역적인 변화이므로, 이 단계에서의 조기 진단과 치료가 가능하다면 환자의 예후 향상에 크게 기여할 수 있을 것이다. 따라서, 본 연구에서는 혈액투석 환자의 혈관내피세포 및 평활근세포의 기능을 조사하고 심혈관계 질환의 발생과 예후 결정에 중요한 인자인 전신염증반응의 지표, 환자의 영양 상태 및 기타 생화학적 지표와의 상관관계를 조사하였다.
방 법 : 임상적으로 안정된 혈액투석 환자 37명 (평균연령 51.8세, 평균투석기간 37.9개월)와 11명의 건강 대조군, 24명의 고혈압 대조군에서 상완동맥 도플러 초음파를 이용하여 혈관내피세포 기능을 측정하였다. 내피세포 의존성 혈관확장능 (FMD), 니트로글리세린을 설하로 투여한 후의 내피세포 비의존성 혈관확장능 (EIV), 최대반응시간 (PT) 등의 지표를 측정하고, 허혈성 심질환 (IHD)의 이환 여부, 환자의 영양 상태, hsCRP 농도 및 다른 생화학적 지표와의 상관관계를 조사하였다.
결 과 : 1. 혈액투석 환자의 FMD와 EIV는 건강 대조군에 비하여 감소되어 있었고, 각 반응의 PT는 두 대조군에 비해 지연되어 있었다. 고혈압 대조군에서는 FMD만 감소되어 있었고 EIV는 정상 대조군과 유사하였다.
2. FMD와 EIV는 혈중 hsCRP 농도와 각각 의미 있는 음의 상관관계가 있었으나, 연령, 투석기간, RAS 차단제의 복용 여부, 알부민, 프리알부민, 총콜레스테롤, 중성지방, 호모시스테인 농도와는 상관관계가 없었다.
3. 투석 환자 중 IHD가 있는 환자가 IHD가 없는 환자에 비하여 평균투석기간이 길었고, SGA에 의해 평가된 영양실조 환자가 많았다. hsCRP의 농도는 IHD가 있는 환자에서 증가되어 있었다 (중앙값: 1.43 vs. 0.15 mg/dL, p<0.05). IHD가 있는 환자에서 FMD (4.1±2.5 vs. 6.4±2.6%, p<0.05)와 EIV (8.7±4.1 vs. 13.8±7.2%, p<0.05)가 유의하게 감소되어 있었다.
결 론 : 혈액투석 환자에서 환자의 전신염증반응은 혈관내피세포와 평활근세포의 기능 결정에 중요한 역할을 할 것으로 생각된다. CRP 농도의 증가가 전신염증반응 존재의 간접적인 지표인지 또는 혈관 기능이상에 직접적으로 작용하는지의 여부와 그 기전에 대해서는 향후 전향적인 연구와 in vitro 실험이 필요할 것으로 사료된다.

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