顾琳　夏春英　邵维斌

[关键词] 沙库巴曲缬沙坦;射血分数降低心力衰竭;终末期肾脏病;血液透析

[中图分类号] R541.6          [文献标识码] C          [文章编号] 1673-9701（2021）14-0155-05

Sacubitril/valsartan in the treatment of end-stage renal disease with heart failure with reduced ejection fraction： a case report

GU Lin   XIA Chunying   SHAO Weibin

Department of Nephrology， People's Hospital Affiliated to Jiangsu University， Zhenjiang   212002， China

[Abstract] Heart failure is a common complication of end-stage renal disease （ESRD）， which seriously affects the quality of life and prognosis of patients， and also causes a great economic burden on individuals and society. Therefore， it is particularly important and urgent to improve heart failure in patients with ESRD. The traditional treatment drugs for chronic heart failure generally refer to angiotensin converting enzyme inhibitors （ACEI） or angiotensin receptor blocker （ARB）， β-receptor blockers， and aldosterone antagonists. The combination of the above three drugs is called the "Golden Triangle"， which can improve myocardial remodeling and reduce the risk of hospitalization and cardiovascular death in patients with heart failure. It is the current basic treatment for chronic heart failure. In recent years， the angiotensin receptor enkephalinase inhibitor sacubitril/valsartan can significantly improve the prognosis of patients with heart failure， and become a new drug for the treatment of heart failure with reduced ejection fraction （HFrEF）. At present， a patient with hemodialysis and heart failure in our blood purification center has significantly improved heart function after using the drug， as described below.

[Key words] Sacubitril/valsartan; Heart failure with reduced ejection fraction; End-stage renal disease; Hemodialysis

沙库巴曲缬沙坦是一种治疗心力衰竭的创新药物，它打破了心力衰竭治疗近20年的困局。慢性肾脏病（Chronic kidney disease，CKD）患者罹患结构相关心脏病的风险增加，尤其是心力衰竭和心律失常[1]。目前全球最大规模多中心的Ⅲ期PARADIGM-HF肾脏亚组分析研究显示，对比传统意义的金三角药物血管紧张素受体转换酶抑制剂（依那普利），沙库巴曲缬沙坦能使心衰患者全因死亡率下降16%，心血管事件死亡下降20%及心衰住院风险下降21%，同时显著延缓肾小球滤过率（Glomerular filtration rate，GFR）下降，减少GFR年丢失率[2]。但严重肾功能不全，GFR<30 mL/min·1.73 m2的患者却未被纳入PARADIGM-HF试验[3]。故目前尚缺乏沙库巴曲缬沙坦治疗心力衰竭合并严重肾功能不全特别是血液透析患者的耐受性和预后数据。现对本院收治的1例长期维持性血液透析合并射血分数降低心衰患者使用沙库巴曲缬沙坦情况进行总结，并报道如下。

1 临床资料

1.1 一般资料

患者女，50岁，因“反复颜面水肿伴尿中泡沫增多3月”，于2015年2月11日在我院肾内科门诊查尿常规：红细胞0～2/HP，隐血1+，蛋白1+，微白蛋白>150 mg/L，管型阴性，肾功能：尿素氮13.8 mmol/L，肌酐263 μmol/L，尿酸509 μmol/L，肾脏B超：右肾大小83 mm×30 mm，左肾大小84 mm×37 mm，雙肾体积缩小，诊断慢性肾功能不全，后就诊于南京军区总医院（具体过程不详）。平素服用百令胶囊、保肾片护肾，碳酸氢钠纠酸，每周促红细胞生成素3000 U皮下注射纠正肾性贫血，未定期门诊随诊及完善血常规、尿常规及肾功能等相关检查。2017年1月12日因“颜面水肿2年，纳差乏力1周”再来我院，门诊查肾功能：尿素氮38.48 mmol/L，肌酐757.6  μmol/L，尿酸633.85 μmol/L，血常规：血红蛋白83 g/L，为进一步诊治收住入院。患者既往体健，否认肝炎、结核，否认高血压、糖尿病及心脏病史。入院查体：血压160/90 mmHg（1 mmHg=0.133 kPa），神清，贫血貌，两肺呼吸音清，未闻及明显干湿啰音，心率87次/min，心律齐，心脏各瓣膜区听诊未闻及杂音，腹软，无肌紧张，全腹无压痛及反跳痛，双肾区无叩击痛，双下肢无明显凹陷性水肿。入……