目的 观察原发性醛固酮增多症(PA)患者血清钠/钾钙磷乘积(Na/KCaP)变化，探讨血清Na/KCaP从高血压患者中筛查PA的效能。方法 2010年1月-2014年1月新疆维吾尔自治区人民医院诊治高血压患者929例，记录性别、年龄、高血压病程、入院次日血压、估算肾小球滤过率(eGFR)、尿液pH值;入院次日检测血清总胆固醇、尿酸、血糖、钠、钾、钙、磷水平，计算血清钙磷乘积及Na/KCaP，采用放射免疫法测定坐位血浆醛固酮浓度(PAC)、血浆肾素活性(PRA)，并计算醛固酮肾素比值(ARR)。采用性别、血清钾、血清钙磷乘积及尿液pH值构建的列线图模型预测PA概率。根据PA诊断标准，929例患者分为PA组137例和非PA组792例，比较上述指标。以血清Na/KCaP三分位切点12。3(mmol/L)-2 和 15。8(mmol/L)-2 为界，929 例患者血清 Na/KCaP＜12。3(mmol/L)-2 者 308 例、12。3～＜15。8(mmol/L)-2者311例、≥15。8(mmol/L)-2者310例，比较PA检出率。采用多因素logistic回归分析高血压患者PA的影响因素;绘制ROC曲线，评估血清钾、血清Na/KCaP、列线图模型预测高血压患者PA的效能。结果 929例高血压患者中 PA 137 例(14。7％)。血清 Na/KCaP＜12。3(mmol/L)-2、12。3～＜15。8(mmol/L)-2、≥15。8(mmol/L)-2者 PA检出率(7。5％、9。6％、27。1％)依次增高(x2=57。024，P＜0。001)。PA 组年龄[(47。90士9。69)岁]大于非 PA 组[(45。00士8。90)岁](t=-3。474，P=0。001)，高血压病程[4。00(1。00，10。00)年]长于非 PA 组[3。00(1。00，7。00)年](Z=-3。059，P=0。002)，女性比率(45。99％)、收缩压[(144。45±20。58)mmHg]、血清 Na/KCaP[(16。98±4。14)(mmol/L)-2]、血清 Na/KCaP≥15。8(mmol/L)-2 比率(61。31％)、尿液 pH 值(6。09±0。69)、列线图模型预测 PA 概率[(26。30(15。90，43。30)％]均高于非 PA 组[36。74％、(140。50±18。50)mmHg、(14。59±3。40)(mmol/L)-2、28。54％、5。89±0。65、15。50(8。70，26。20)％](P＜0。05)，血清尿酸[(312。49±79。53)μmol/L]、钾[(3。63±0。39)mmol/L]、钙磷乘积[(2。39±0。42)(mmol/L)2]均低于非 PA 组[(332。25±93。42)μmol/L、(3。86±0。36)mmol/L、(2。62±0。54)(mmol/L)2](P＜0。05)，体质量指数、舒张压、eGFR、总胆固醇、血糖、血清钠与非PA组比较差异均无统计学意义(P＞0。05)。血清 Na/KCaP(OR=1。168，95％CI:1。109～1。230，P＜0。001)、血清 Na/KCaP≥15。8(mmol/L)-2(OR=4。419，95％CI:2。627～7。434，P＜0。001)是高血压患者 PA 的影响因素。血清钾、血清Na/KCaP、列线图模型分别以3。5 mmol/L、16。1(mmol/L)-2、21％为最佳截断值，预测高血压患者PA的AUC分别为0。614(95％CI:0。571～0。660，P＜0。001)、0。691(95％CI:0。643～0。740，P＜0。001)、0。695(95％CI:0。646～0。743，P＜0。001)，灵敏度分别为37。2％、60。6％、62。8％，特异度分别为85。5％、74。2％、64。8％，准确率分别为78。4％、72。2％、64。5％。血清Na/KCaP预测高血压患者PA的AUC大于血清钾(Z=3。251，P=0。001)，与列线图模型比较差异无统计学意义(Z=1。166，P=0。869)。结论 血清Na/KCaP≥15。8(mmol/L)-2的高血压患者PA的风险较大，血清Na/KCaP对高血压患者PA有一定筛查价值。
Role of serum sodium/potassium-calcium-phosphorus product in screening primary aldosteronism
Objective To observe the changes of serum sodium/potassium-calcium-phosphorus product(Na/KCaP)in patients with primary aldosteronism(PA),and to explore the efficacy of serum Na/KCaP on screening PA in hypertensive patients.Methods Totally 929 patients with hypertension were diagnosed and treated in the People's Hospital of Xinjiang Uygur Autonomous Region from January,2010 to January,2014.The gender,age,hypertension course,blood pressure on the next day after admission,estimated glomerular filtration rate(eGFR)and urine pH value were recorded.The serum total cholesterol,uric acid,plasma glucose,sodium,potassium,calcium and phosphorus levels were detected on the next day after admission.The serum calcium-phosphorus product and Na/KCaP were calculated.The plasma aldosterone concentration(PAC)and plasma renin activity(PRA)were measured by radioimmunoassay,and aldosterone to renin ratio(ARR)was calculated.The gender,serum potassium,serum calcium-phosphorus product and urine pH value were used to predict PA probability.According to the gold standard of PA diagnosis,929 patients were divided into PA group(n=137)and non-PA group(n=792),and the above parameters were compared between two groups.Taking the serum Na/KCaP tertile cut-off points of 12.3(mmol/L)-2 and 15.8(mmol/L)-2 as boundaries,the PA detective rates were compared among 308 patients with serum Na/KCaP＜12.3(mmol/L)-2,311 patients with Na/KCaP 12.3 to＜15.8(mmol/L)-2,and 310 patients with Na/KCaP 15.8(mmol/L)-2.Multivariate logistic regression was used to analyze the influencing factors of PA in hypertensive patients.ROC curve was plotted to evaluate the efficiencies of serum potassium,serum Na/KCaP and nomogram models on diagnosing PA in hypertensive patients.Results In 929 patients,137(14.7％)developed PA.The detective rate of PA increased sequentially in patients with serum Na/KCaP＜12.3(mmol/L)-2,Na/KCaP 12.3 to＜15.8(mmol/L)-2,and Na/KCaP ≥15.8(mmol/L)-2(7.5％,9.6％,27.1％)(x2=57.024,P＜0.001).The patients were older in PA group[(47.90±9.69)years]than in non-PA group[(45.00±8.90)years](t=-3.474,P=0.001).The hypertension course was longer in PA group[(4.00(1.00,10.00)years]than that in non-PA group[(3.00(1.00,7.00)years](Z=-3.059,P=0.002).The female ratio,systolic blood pressure,serum Na/KCaP,proportion of serum Na/KCaP 15.8(mmol/L)-2,urine pH value and nomogram model for predicting PA probability were higher in PA group[45.99％,(144.45±20.58)mmHg,(16.98±4.14)(mmol/L)-2,61.31％,6.09±0.69,26.30(15.90,43.30)％]than those in non-PA group[36.74％,(140.50±18.50)mmHg,(14.59±3.40)(mmol/L)-2,28.54％,5.89±0.65,15.50(8.70,26.20)％](P＜0.05).The serum uric acid,potassium and calcium-phosphorus product were lower in PA group[(312.5±79.5)μmol/L,(3.63±0.39)mmol/L,(2.39±0.42)(mmol/L)2]than those in non-PA group[(332.25±93.42)μmol/L,(3.86±0.36)mmol/L,(2.62±0.54)(mmol/L)2](P＜0.05).There were no significant differences in the body mass index,diastolic blood pressure,eGFR,total cholesterol,plasma glucose and serum sodium between two groups(P＞0.05).The serum Na/KCaP(OR=1.168,95％CI:1.109-1.230,P＜0.001),and serum Na/KCaP ≥15.8(mmol/L)-2(OR=4.419,95％CI:2.627-7.434,P＜0.001)were the influencing factors of PA in hypertensive patients.When the optimal cut-off values of serum potassium,serum Na/KCaP and nomogram model were 3.5 mmol/L,16.1(mmol/L)-2 and 21％,the AUCs for diagnosing PA in hypertensive patients were 0.614(95％CI:0.571-0.660,P＜0.001),0.691(95％CI:0.643-0.740,P＜0.001),and 0.695(95％CI:0.646-0.743,P＜0.001),the sensitivities were 37.2％,60.6％and 62.8％,the specificities were 85.5％,74.2％and 64.8％,and the accuracy rates were 78.4％,72.2％and 64.5％,respectively.The AUC of serum Na/KCaP for diagnosing PA was greater than that of serum potassium(Z=3.251,P=0.001),and showed no significant difference from the nomogram model(Z=1.166,P=0.869).Conclusion Hypertensive patients with serum Na/KCaP ≥15.8(mmol/L)-2 have a great risk of PA,therefore the serum Na/KCaP has a screening value to the diagnosis of PA in hypertensive patients.
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