超声造影基线肾皮质血流灌注对重度肾动脉狭窄支架治疗短期预后的观察性研究

An observational study of the effect of baseline renal cortical blood perfusion with contrast-enhanced ultrasound on short-term outcomes of stent implantation for severe renal artery stenosis

目的观察超声造影基线肾皮质血流灌注参数中上升支曲线下面积(wash-in area under curve,iAUC)对重度肾动脉狭窄(renal artery stenosis,RAS)患者支架治疗短期预后的影响。方法回顾性分析2017年10月至2019年12月北京医院收治的82例单侧重度RAS行支架治疗的患者,根据术前超声造影基线患肾皮质血流灌注参数iAUC,分为灌注不良组(iAUC<850.0 dB×s)37例和灌注良好组(iAUC≥850.0 dB×s)45例,比较两组基线和临床影像学资料。随访(11.5±1.7)个月,采用Kaplan-Meier生存曲线和Log-rank检验比较两组不良心肾血管事件发生和高血压治疗情况。结果与灌注良好组比较,灌注不良组高血压病程长,糖尿病患者更多,收缩压、舒张压、24 h平均收缩压、24 h平均舒张压更高,肾小球滤过率更低,RAS程度更重,上升支和下降支曲线下面积、峰值强度更低,平均渡越时间更长,降糖治疗率更高(均P<0.05)。Kaplan-Meier生存曲线和Log-rank检验分析显示,灌注良好组心肾血管事件(HR=0.361,95%CI=0.144~0.907,P=0.012)和肾功能恶化率(HR=0.286,95%CI=0.090~0.914,P=0.035)的发生风险均显著低于灌注不良组。灌注良好组高血压治疗有效率显著高于灌注不良组(93.3%对59.5%,P<0.001),但两组高血压改善率(60.0%对43.2%)和治愈率(28.9%对16.2%)差异无统计学意义(均P>0.05)。结论超声造影基线肾皮质血流灌注不良的重度RAS患者常合并糖尿病,高血压病程更长,肾小球滤过率明显减低和RAS更重,且支架植入术后短期预后不良。

Objective To observe the effect of the cortical blood perfusion parameter of wash-in area under curve(iAUC)with contrast-enhanced ultrasound(CEUS)on the effect of short-term outcomes of stent implantation in patients with severe renal artery stenosis(RAS).Methods Retrospective analysis was performed on 82 patients with unilateral severe RAS who received stent implantation in Beijing Hospital from October 2017 to December 2019.According to the baseline iAUC before CEUS,all patients were divided into the poorly-perfused group(iAUC<850.0 dB×s)(37 cases)and the well-perfused group(iAUC≥850.0 dB×s)(45 cases).Baseline and perioperative clinical-imaging data were analyzed between the two groups.Followed up for 10-12(11.5±1.7)months,Kaplan-Meier survival curves and Log-rank test were used to analyze the rate of adverse cardiac and renal vascular events and hypertension control rates.Results Compared with the well-perfused group,the poorly-perfused group showed a longer course of hypertension,more diabetic patients,higher systolic blood pressure,diastolic blood pressure,24 h average systolic blood pressure,and 24 h average diastolic blood pressure,lower glomerular filtration rate,and severe renal artery stenosis.Besides,the iAUC,wash-out AUC and the peak intensity were lower,the average transit time was longer,and the hypoglycemic treatment rate was higher(all P<0.05).Kaplan-Meier survival curve and Log-rank test analysis showed that the occurrence of cardio-renal vascular events(HR=0.361,95%CI=0.144-0.907,P=0.012)and renal function deterioration rate(HR=0.286,95%CI=0.090-0.914,P=0.035)in the well-perfused group were significantly lower than those in the poorly-perfused group.The blood pressure results demonstrated that the effective rate of hypertension treatment in the well-perfused group was significantly higher than that in the poorly-perfused group(93.3%vs 59.5%,P<0.001),but the improvement rate of hypertension(60.0%vs 43.2%)and cure rate(28.9%vs 16.2%)were not statistically significant between the two groups(all P>0.05).Conclusions Severe RAS patients with decreased baseline iAUC often have diabetes,longer duration of hypertension,significantly reduced glomerular filtration rate and more severe RAS,short-term outcomes are worse with stent implantation.