慢性肾功能不全患者微创经皮肾镜取石术后的中期随访研究

Medium-term follow-up of minimally invasive percutaneous nephrolithotomy in patients with renal function impairment

目的随访观察慢性肾功能不全患者行微创经皮肾镜取石术后的肾功能情况，探讨预测术后肾功能恶化的指标。方法选取2009年1月至2011年12月因肾结石或输尿管上段结石行微创经皮肾镜取石术患者78例，术前预计肾小球滤过率（estimatedglomerularfiltrationrate，eGFR）为（38．4±12．8）ml／（min·1．73m2）。术后随访1年，将患者分为肾功能好转或维持不变组（第1组）和。肾功能恶化组（第2组）。第1组：男41例，女25例，年龄（42．8±16．3）岁；第2组：男7例，女5例，年龄（45．3±14．2）岁。第1组体质指数（BMI）（24．3±4．1）kg／m2、第2组（25．4±5．2）kg／m2。高血压病患者第1组35例，2组10例；糖尿病患者第1组15例，第2组7例；开放手术史第1组19例，第2组4例；ESWL史第1组19例，第2组4例。轻度肾积水第1组22例，第2组4例；中度或重度肾积水第1组44例，第2组8例。鹿角形结石第1组22例，第2组7例。第1组术中单通道53例，多通道13例；第2组术中单通道10例，多通道2例。第1组手术时间为（78．2±30．4）min，第2组为（80．3±32．3）min。结果本组78例术后1个月复查CT平扫发现结石完全清除67例，其中第1组56例，第2组11例，清除率为85％。术后1年eGFR平均为（45．1±15．8）ml／（min·1．73m2），与术前比较差异有统计学意义（P〈0．05）。肾功能好转24例（31％），维持不变42例（54％），下降12例（15％）。通过多因素回归分析发现，糖尿病是预测微创经皮肾镜取石术后肾功能恶化的重要因素（OR=3．85，P〈0．05）。结论肾功能不全患者微创经皮肾镜取石术后，85％的患者在1年随访期间内肾功能好转或者维持不变。微创经皮肾镜取石术对于肾功能不全的结石患者是一种安全有效的治疗手段。研究结果显示糖尿病是预测术后肾功能恶化的指标，对于合并糖尿病的结石患者行微创经皮肾镜取石术后需要积极的血糖监测和治疗。

Objective To evaluate the medium-term outcomes of minimally invasive percutaneous nephrolithotomy in patients with renal function impairment. Methods Data of 811 patients who underwent minimally invasive percutaneous nephrolithotomy between Jan. 2009 and Dec. 2011 were retrospectively col- lected. Seventy-eight patients had a preoperative estimated GFR of 30 -59 ml/（ min · 1.73m2）. The mini- mum follow-up was 1 year. Patients were divided into group 1 （ improved or stable disease） and group 2 （worsened disease）. Patient age was （42.8 ± 16.3 ） and （45.3 ± 14.2） separately, with male patients 41 and 7, female patients 25 and 5 respectively. Body mass index were （24.3 ± 4. 1 ） kg/m2 and （25.4 ±5.2） kg/m2 , history of open surgery or ESWL were 19 and 4. Mild hydronephrosis were 22 and 4. Staghorn stone were 22 and 5. Multiple access were 13 and 2. Operative time was （78.2 ±30.4） min and （80.3 ±32.3） min. Stone-free rate 1 month postoperatively were recorded. Multiple regression analysis was used. Results The stone free rate at 1 month postoperatively was 85% by CT scan. Preoperative eGFR was （38.4±12.8） ml/（min · 1.73m2）, and 1 year postoperative eGFR was （45.1 ±15.8） ml/（min · 1.73m2） in 78 patients. Renal function had improved in 31% of patients, but it remained the same or deteriorated in 54% and 15% , respectively at 1 year follow-up. On multivariate regression analysis, diabetes was associat- ed with the deterioration of renal function. Conclusions At medium-term follow-up, renal function was maintained or improved in 85% of patients with chronic kidney disease who underwent minimally invasive percutaneous nephrolithotomy. Minimally invasive pereutaneous nephrolithotomy could be an effective and safe option for the patients with chronic renal function impairment. Diabetes mellitus was independent pre- dictive factor of renal function impairment. Therefore, patients with diabetes should be followed up carefully. Medical management is needed if necessary.