［关键词］ 冠心病；代谢综合征；慢性肾脏病；相关性
clinical investigation of correlation between metabolic syndrome and chronic kidney disease in coronary heart disease
［abstract］ objective to investigate the relationship between coronary artery disease(cad，metabolic syndrome（ms）and chronic kidney disease (ckd) including minor renal dysfunction).methods a retrospective study was performed in 733 patients who had been treated in our cardiovasology department and cardiothoracic surgery department in 2000～2004.all patients suspected of coronary artery disease underwent a selective coronary angiography and received a survey of risk factors during the hospitalization. according to the existence of cad or not，these patients were divided into two groups. the correlation between coronary artery disease and chronic kidney disease was examined.according to the existence of ms or not，these patients were divided into different groups.the relationship between the components of metabolic syndrome and ckd was evaluated. logistic regression，cmh test and chisquare test were used in the statistic analysis.results we observed that significant correlations between the severity of the coronary artery stenosis and levels of chronic kidney disease（γ=0.1911，p<0.001）.metabolic syndrome had higher incidence of chronic kidney disease in patients with coronary artery disease.logistic regression analysis showed that hyperglycemia，hypertension，obesity，hypercholesterolemia were independent risk factors for chronic kidney disease. hyperglycemia and hypertension were important risk factors for chronic kidney disease and minor renal dysfunction (plasma glucose or=35.237，hypertension or=38.078).conclusion significant correlations between the severity of the coronary artery stenosis and levels of renal insufficiency is observed.it is suggested that the development of chronic renal insufficiency increases the risk of coronary artery disease.metabolic syndrome were significantly correlated with coronary artery disease and chronic kidney disease.the risk increased as a result of a cumulative effect of the components of metabolic syndrome.hyperglycemia and hypertension were important risk factors for chronic kidney disease and minor renal dysfunction.
［key words］ coronary artery disease;metabolic syndrome;chronic kidney disease;correlation
流行病学调查已确定了冠心病的主要危险因素有高血压、糖尿病、高脂血症、肥胖等。这些危险因素常合并发生在同一个体，1999年who定义为代谢综合征（metabolic syndrome，ms）［1，2］。根据我国所做的最新诊断标准建议，只要具备肥胖、高血压、高血糖和血脂水平异常中的任何3项或以上指标，即可被诊断为代谢综合征。随着人民生活水平不断地提高，代谢综合征的发病率也日益增加［3］。代谢综合征既包括高血糖和高血压，且其他组成因子也可以促进心血管疾病尤其是冠心病的发生，从而增加冠心病死亡的风险。而慢性肾脏病与冠心病发生、 发展 及预后关系密切，本 研究 通过对部分住院患者资料进行回顾性研究，以探讨冠心病、代谢综合征与慢性肾脏病的关系，进而更进一步证实慢性肾脏病对冠心病危险程度的影响，对指导临床 治疗 具有深远的意义。
1 对象与方法
1.1 研究对象 选择我院2000年1月～2004年12月期间心内科和胸外科收治住院患者中符合以下入选标准：(1)有冠脉造影结果；(2)有身高、体重、血生化、血脂等检查结果；(3)除外急性肾功能不全患者。
1.2 方法 收集住院时测定的身高、体重，并据此 计算 身体质量指数［bmi，体重(kg)/身高(m2)］；记录患者有无高血糖、高血压、高血脂病史。收集住院期间尿常规、血肌酐、血糖、总胆固醇(tc)、高密度脂蛋白(hdl)、甘油三酯(tg)等。
1.3 冠心病、代谢综合征与慢性肾脏病的定义及诊断标准
1.3.1 冠心病（cad） 参照“国际疾病分类”第9版(codes 402)确立的冠心病定义为临床、心电图和实验室检查诊断的心肌梗死；冠状血管造影证实的冠状动脉疾病；接受冠状动脉旁路手术或经皮腔内血管成形术；临床诊断的急性冠状动脉综合征。
1.3.2 代谢综合征 按中华医学会糖尿病分会2004标准［4］定义为：(1)超重和(或)肥胖，bmi≥25kg/m2；(2)血脂紊乱，tg≥1.7mmol/l和(或)hdl<0.9mmol/l(男性)或1.0mmol/l(女性)；(3)高血压≥140/90mmhg和(或)已确诊高血压并治疗者；(4)高血糖，空腹血糖＞6.1mmol/l，餐后2h血糖＞17.8mmol/l和（或)已确诊糖尿病或治疗者。代谢综合征指3项或3项以上异常。
1.3.3 慢性肾脏病(cad) 慢性肾脏病的诊断和分期标准［5］如下：（1）按coekerokgault公式计算肾小球滤过率(gfr)。gfr 60～89ml/（min·1.73m2）为轻度gfr降低；gfr 30～59ml/（min·1.73m2）为中度gfr降低；gfr＜29ml/(min·1.73m2）为重度gfr降低；(2)尿蛋白阳性；其中微量白蛋白尿或临床蛋白尿列入轻度肾损害者。
1.4 统计学方法 在第二军医大学统计学教研室指导下，用epidata 3.0软件建立冠脉造影病人资料数据库。随访汇总后对原始调查表进行逻辑查错，再录入数据库。数据处理采用sars软件。按有、无冠心病以及是否合并代谢综合征进行分组，采用卡方检验、cmh检验和logistic回归分析。
2 结果
符合入选标准的共733例，本研究主要以选择性冠脉造影为诊断依据（任何冠状动脉病变狭窄均≥50%），诊断为冠心病者580例(阳性组)，无冠状动脉狭窄者153例(阴性组)。其中冠心病组患慢性肾脏病511例，非冠心病组患慢性肾脏病89例，两组差异有非常显著性（p＜0.001），见表1。
表1 冠心病组与非冠心病组慢性肾脏病发病情况
根据不同肾功能水平与冠脉病变支数分组比较，肾功能损害程度越重，冠脉多支病变发生率越高（γ=0.1911，p<0.001），见表2。
表2 不同肾功能水平冠脉病变程度比较 例（%）
注：kendall相关系数(r)=0.1911，p<0.0001
合并代谢综合征患慢性肾脏病313例，非合并代谢综合征患慢性肾脏病198例，两组差异有显著性(p＜0.05)，见表3。
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