氯胺酮相关性泌尿系统损害的积分分期评估及应用价值

The staging evaluation of ketamine associated urinary dysfunction based on a scoring system

目的 建立氯胺酮相关性泌尿系统损害的积分分期系统,并评价其性能和临床意义.方法 回顾性分析我院2009年9月至2015年9月收治的135例氯胺酮相关性泌尿系统损害患者的临床资料.男111例,女24例,年龄18 ～41岁,平均（24.8±4.7）岁.所有患者根据膀胱和上尿路受累情况分为3期,采用阶梯化治疗策略,泌尿系统影像学无明显异常者为Ⅰ期,采用行为和药物综合治疗.影像学或尿动力提示膀胱病变,而上尿路无形态学和功能学异常者为Ⅱ期,在保守治疗基础上行膀胱水扩张术及定期膀胱灌注.经上述干预后,上尿路影像学及肾功能异常持续进展者为Ⅲ期,在上述治疗效果欠佳时考虑行肠膀胱扩大术或膀胱全切原位新膀胱术.评价治疗前和治疗后1个月膀胱日记反映的排尿情况,PUF评分,ICPI和ICSI评分.分析各项资料与临床分期的相关性,建立评分分期系统,比较评分估算的分期与临床分期的符合程度,并用受试者工作特征（ROC）曲线检查该积分系统预测的敏感性和特异性.结果 3期患者在阶梯化治疗后排尿间隔时间、平均尿量、夜尿次数、PUF评分、ICPI和ICSI评分上均有明显改善.患者年龄（P=0.018）、氯胺酮滥用时长（P=0.006）、eGFR（P=0.001）、ALT（P=0.037）、γ-GT（P＜0.001）、膀胱壁增厚（P=0.013）、输尿管病变（P ＜0.001）、肾积水（P＜ 0.001）和核素肾图异常比例（P=0.01）与临床分期相关.共107例（79.2％）患者根据积分得出的分期与临床分期符合（3期分别有30、65和12例）.该分期系统在判断Ⅰ期和Ⅱ期临界值时,积分ROC的曲线下面积（AUC）为0.922,而判断Ⅱ期和Ⅲ期临界值时,AUC为0.978.结论 通过氯胺酮滥用史、实验室检验及影像学检查建立的氯胺酮相关性泌尿系统损害的积分分期系统,可能有助于评估膀胱及上尿路病情发展阶段,对治疗方式的选择有一定的指导作用.

Objective To establish the a staging system based on scoring of ketamine associated urinary dysfunction （KAUD） and evaluate its diagnosis performance and clinical value.Methods A retrospective analysis of 135 admitted KAUD patients from September 2009 to September 2015 was performed.All patients were classified into three stages according to bladder and upper urinary tract impairment, and treated with subsequent strategy.The behavioral modification and pharmacotherapy was performed in stage Ⅰ which image investigation was normal.Hydrodistension and intravesical perfusion was used if pharmacotherapy failed in stage Ⅱ patients who had bladder impairment in image or urodynamics.Augmentation cystoplasty or cystectomy with urinary diversion was optional if aforementioned treatment failed in stage Ⅲ who had upper urinary tract involvement and abnormal renal function.The voided volume, micturition interval, and nocturnal void frequency as recorded in their 3-day bladder diary, PUF, ICPI and ICSI score after treatment in one month, were compared with their baseline data prior to treatment.Ketamine abusing history, renal and liver function, bladder and upper urinary tract changes, urodynamics and radioisotope renography correlation with stages were analyzed.A scoring system was established and the concordance between the clinical staging and model staging of each patient was compared.Receiver operating characteristic curve was employed to testify the sensitivity and specificity.Results There were 39, 80 and 16 patients included in each stage respectively.After subsequent strategy of treatment, voided volume, micturition interval, and nocturnal void frequency, PUF, ICPI and ICSI were improved significantly.Age （P =0.018）, ketamine abusing history （P =0.006）, eGFR （P =0.001）, ALT （P =0.037）, γ-GT （P 〈 0.001）, bladder （P =0.013） and ureteral changes （P 〈 0.001）, hydronephrosis （P 〈 0.001） and radioisotope renography abnormality （P =0.01） were correlated with clinical stages.In total, 107 cases＇ stages based on scoring were accordant with clinical stages （30, 65 and 12 cases in each stage respectively）.AUC of the scoring model ROC was 0.922 on cut point between Ⅰ and Ⅱ stages and AUC of the scoring model ROC was 0.978 on cut point between Ⅱ and Ⅲ stages.Conclusions We presented a scoring staging system of KAUD based on ketamine abusing history, laboratory test results, and imaging findings.It might be helpful to evaluate the progression on bladder and upper urinary tract, and provide a reference for treatment.This staging system based on scoring still needs further validation and improvement.