투석을 시작하는 만성신부전 환자에서 관상동맥 질환의 유병률과비침습적 선별검사의 임상적 유용성 = The Prevalence of Coronary Artery Disease in Patients withEnd Stage Renal Disease at the Initiation of Dialysisand the Accuracy of Noninvasive Tests

다국어 초록 (Multilingual Abstract)

Purpose : Coronary artery disease (CAD) is a major cause of mortality in chronic dialysis patients, and often occurs within the first year of dialysis. However, there is little evidence based on prospective trials in incident dialysis patients, and nobody knows which noninvasive test is best for screening the CAD in these patients. Therefore, we conducted this study to examine the prevalence of CAD and the accuracy of noninvasive tests that we can easil do for detection of CAD in incident dialysis patients.
Methods : We evaluated the prevalence of CAD using resting ECG, 2D echocardiography, 99m Tc tetrofosmin single photon emission computed tomography(SPECT) and the accuracy of these non- invasive screening tests in all 84 incident dialysis patients from March 2005 to September 2006 at the Hallym University SH Hospital in Korea.
Results : Of eighty-four patients, 23 (27.4%) had significant CAD. Fifteen (18.9%) patients had ischemic ECG change, and its positive predictive value and sensitivity were 66.7% and 45.0%, respectively. Resting 2D echocardiography had positive predictive value of 77.3%, sensitivity of 63.6% and lower specificity of 50.0%. 99m Tc tetrofosmin SPECT had positive predictive value of 73.3% and sensitivity of 73.3%.
Conclusion : The prevalence of CAD in patients at the initiation of dialysis was 27.4%. 99m Tc tetrofosmin SPECT may be helpful for diagnosing CAD with ECG and 2D-echocardiography because of high sensitivity and positive predictive value.

국문 초록 (Abstract)

배 경 : 관상동맥질환은 투석을 시행하는 만성 신부전 환자의 주된 사망 원인이며 특히 투석 시작 1년 이내 대부분 발생하여 조기 진단 및 치료가 중요하나 선별검사의 정확도에 대해서는 보고마다 차이를 보였다. 본 저자들은 투석을 시작하는 단계에서 관상동맥질환에 대한 선별검사를 시행하여 관상동맥질환의 유병률을 알아보고 각 검사의 정확도를 비교하여 보았다.
방 법 : 2005년 3월부터 2006년 9월까지 투석 치료를 시작한 환자 84명을 대상으로 하여 안정시 심전도, 심초음파, 약물부하 심근 SPECT를 시행하여 가역적인 관류 결손을 보이는 경우 관상동맥 조영술을 시행하여 질병 여부를 확인하였다.
결 과 : 투석을 시작하는 만성신부전 환자에서 관상동맥질환의 유병률은 27.4%였고 심전도 변화는 18.9%에서 있었으며 양성 예측도는 66.7%였으나 민감도는 45.0%로 낮았다. 심초음파에서 이상소견은 29.0%에서 관찰되었고 양성 예측도는 77.3%였으며 민감도 및 특이도는 각각 63.6%와 50.0%였다. 심근 SPECT의 경우 양성 예측도 및 민감도는 모두 73.3%였다.
결 론 : 투석을 시작하는 단계에서 관상동맥질환의 유병율은 27.4%로 높았고 심근 SPECT의 양성 예측도와 민감도가 높아 심전도 및 심초음파와 더불어 관상동맥질환의 선별검사로 이용될 수 있을 것으로 생각된다.

참고문헌 (Reference)

1 배우균, "만성 신부전 환자에서 관상동맥질환의 비침습적 검사" 대한신장학회 24 (24): 407-413, 2005

2 Knutsen R, "The predictive value of resting electrocardiograms for 12-year incidence of coronary heart disease in the Honolulu Heart Program" 41 : 293-302, 1988

3 Parfrey PS, "The clinical epidemiology of cardiac disease in chronic renal failure" 10 : 1606-1615, 1999

4 Korean Society of Nephrology Registry Committee, "Renal replacement therapy in Korea-Insan Memorial Dialysis Registry 2001" 21 (21): S189-S211, 2002

5 Kim SB, "Prevalence of coronary artery disease using thallium-201 single photon emission computed tomography among patients newly undergoing chronic peritoneal dialysis and its association with mortality" 24 : 448-452, 2004

6 Nakamura S, "Prediction of coronary artery disease and cardiac events using electrocardiographic changes during hemodialysis" 36 : 592-599, 2000

7 Boudreau RJ, "Perfusion thallium imaging of type I diabetes patients with end stage renal disease: comparison of oral and intravenous dipyridamole administration" 175 : 103-105, 1990

8 "K/DOQI Workgroup: K/DOQI clinical practice guidelines for cardiovascular disease in dialysis patients" 45 (45): S1-S153, 2005

9 Schmidt A, "Informational contribution of noninvasive screening tests for coronary artery disease in patients on chronic renal replacement therapy" 37 : 56-63, 2001

10 Marwick TH, "Ineffectiveness of dipyridamole SPECT thallium imaging as a screening technique for coronary artery disease in patients with end-stage renal failure" 49 : 100-103, 1990

11 Elsner D, "How to diagnose and treat coronary artery disease in the uraemic patient: an update" 16 : 1103-1108, 2001

12 Goldsmith DJ, "Coronary artery disease in uremia: Etiology, diagnosis, and therapy" 60 : 2059-2078, 2001

13 "Causes of death. United States Renal Data System" 32 (32): S81-S88, 1998

14 Sarnak MJ, "American Heart Association Councils on Kidney in Cardiovascular Disease, High Blood Pressure Research, Clinical Cardiology, and Epidemiology and Prevention : Kidney disease as a risk factor for development of cardiovascular disease: a statement from the American Heart Association Councils on Kidney in Cardiovascular Disease, High Blood Pressure Research, Clinical Cardiology, and Epidemiology and Prevention" 42 : 1050-1065, 2003