著明な血漿BNP高値を示した心不全合併透析患者の1例

Marked Elevation of Plasma BNP Concentration in Patient with Heart Failure and Chronic Hemodialysis: a case report

　患者は51歳，男性．主訴は呼吸困難．27歳時にネフローゼ症候群，高血圧の診断を受け，42歳時に透析導入となった（心胸郭比44％）．48歳時，心不全にて当院初診（心胸郭比60％）．心電図は洞調律，ST-T変化を伴う左室肥大あり．心エコーでは左室壁厚13mm（対称性），左室拡張末期径80mm，左室内径短縮率7％であり，少量のpimobendanとdenopamineにて症状は改善．しかし，50歳時より心不全が悪化した（血漿BNP8,800pg／ml）．一時軽快するも（血漿BNP6,000pg／ml），今回51歳時，心不全が再増悪し入院（血漿BNP16,300pg／ml．心胸郭比は71％，心電図ではQRSの波高の低下およびQRS幅の増大が認められ，心エコーでは左室壁厚が菲薄化（8mm），左室拡張末期径はさらに増大（94mm），左室内径短縮率4％となった．病状は難治性であり，2ヵ月後には心室頻拍を発症し（血漿BNP33,500pg／ml），3ヵ月後には心室細動となり死亡．血漿BNPは心拡大とともに著明に増加した．

A 51-year-old male presented with dyspnea at rest. His past history revealed nephrotic syndrome and hyper-tension at the age of 23 and initiation to hemodialysis at the age of 42 (CTR ; cardiothoracic ratio 44%). At the age of 48 years, he visited our hospital for the first time because of congestive heart failure (CTR 60%). ECG showed sinus rhythm and left ventricular hypertrophy with a strained pattern. Echocardiography revealed left ventricular dilatation, concentric left ventricular hyper-trophy and decreased systolic function. Oral use of pimobendan (1.25 mg/day) and denopamine (10 mg/day) was effective until he reached 50 years of age. when congestive heart failure reappeared with a plasma BNP concentration of 8,800 pg/ml. As his heart failure had further deteriorated by the age of 51 years (CTR 71%), he was admitted to hospital. Plasma BNP concentration was elevated up to 16,300 pg/ml. ECG showed dimini-shed and wide QRS configuration. Echo-cardiography revealed severe left ventricular dilatation, severely de-creased systolic function and myocardial wall thinning. Ventricular tachycardia occurred when plasma BNP concentration reached 33,500 pg/ml. His general condi-tion deteriorated and he died suddenly of ventricular fibrillation in spite of amiodarone administration 3 months after admission.