儿童肾性急性肾损伤病因及预后影响因素研究

Etiological and Prognostic Factors of Acute Kidney Injury in Children Secondary to Intrinsic Renal Diseases

背景急性肾损伤(AKI)作为临床上一种较为常见的综合征,发病率高,致死率高,存活患者预后差,且目前尚无特效治疗药物,因此引起了广泛重视,尤其是关于儿童AKI。但是目前缺乏儿童肾性AKI的病因及预后影响因素的相关分析。目的探讨儿童肾性AKI的病因及预后影响因素,以期进一步提高儿童肾性AKI的临床研究水平。方法回顾性选取2014年6月—2016年4月在西安市儿童医院肾脏科住院以肾脏基础疾病起病(原发性肾病综合征、IgA肾病、紫癜性肾炎等)的肾性AKI患儿108例为研究对象。收集所有患儿的一般资料;按照患儿年龄分为婴儿期(年龄≤1岁)、幼儿期(1岁<年龄≤3岁)、学龄前期(3岁<年龄<7岁)、学龄期(年龄≥7岁);AKI分期分为1、2、3期。患儿出院后即开始随访并进行疗效评估。分析患儿病因及预后的影响因素。结果 108例患儿病因主要为原发性肾病综合征56例(51.9%),急性链球菌感染后肾小球肾炎26例(24.1%)。108例患儿中,婴儿期30例(27.8%)[病因主要为原发性肾病综合征28例(93.4%)],幼儿期20例(18.5%)[病因主要为原发性肾病综合征14例(70.0%)],学龄前期28例(25.9%)[病因主要为急性链球菌感染后肾小球肾炎10例(35.7%),原发性肾病综合征8例(28.6%)],学龄期30例(27.8%)[病因主要为急性链球菌感染后肾小球肾炎15例(50.0%),原发性肾病综合征6例(20.0%)]。108例患儿中,1期70例(64.8%),2期27例(25.0%),3期11例(10.2%)。1期患儿病因主要为原发性肾病综合征42例(60.0%),急性链球菌感染后肾小球肾炎16例(22.8%);2期患儿病因主要为原发性肾病综合征10例(37.0%),急性链球菌感染后肾小球肾炎7例(25.9%);3期患儿病因主要为原发性肾病综合征4例(36.3%),急性链球菌感染后肾小球肾炎3例(27.3%)。108例患儿总有效率为83.3%(90/108)。AKI分期3期患儿治疗有效率低于AKI分期1、2期(P<0.05);不同大量蛋白尿情况、低蛋白血症情况、高血压情况患儿治疗有效率比较,差异有统计学意义(P<0.05)。多因素Logistic回归分析结果显示,大量蛋白尿、低蛋白血症、高血压是肾性AKI患儿预后的影响因素(P<0.05)。结论儿童肾性AKI的病因众多,主要致病原因是原发性肾病综合征、急性链球菌感染后肾小球肾炎及间质性肾炎,并且婴儿期、学龄前期、学龄期的患儿容易发生肾性AKI,经积极治疗绝大部分患儿预后较好,但是受大量蛋白尿、低蛋白血症、高血压等因素的影响。

Background Acute kidney injury（AKI） is a common clinical syndrome characterized by high rates of morbidity and mortality and poor prognosis.However,there are no wonder drugs for this disease.Recently,AKI,especially AKI in children has gradually attracted widespread attention,but there is still lack of articles about analyzing the etiological and prognostic factors of AKI in children.Objective To explore the associated factors for etiology and prognosis of AKI in children secondary to intrinsic renal diseases,with a view to further improving the clinical research level of the disease.Methods The participants enrolled in this study were 108 children with AKI secondary to intrinsic renal diseases,primary nephrotic syndrome（PNS）,IgA nephropathy（IgAN）,or purpura nephritis（PN）,and so on,treated in Xi′an Children′s Hospital between June 2014 and April 2016.We did a review of the data of the children,and divided them into age groups of infancy,early childhood,preschool age,school age according to the age,and assigned them to groups of stage 1,2,and 3 AKI according to the staging system for AKI,respectively.Follow-up and efficacy assessment were performed after discharge.The associated factors for etiology and prognosis of the children were analyzed.Results Of the 108 cases with AKI,51.9%（56/108） were caused by PNS,24.1%（26/108） by glomerulonephritis due to acute streptococcal infection;27.8%（30/108） were in infancy〔93.4%（28/30） of them were caused by PNS〕;18.5%（20/108） were in early childhood〔70.0%（14/20） of them were caused by PNS〕;25.9%（28/108） were in preschool age〔35.7%（10/28） were caused by glomerulonephritis due to acute streptococcal infection,and 28.6%（8/28） were by PNS〕;27.8%（30/108） were in school age〔50.0%（15/30） of them were caused by glomerulonephritis due to acute streptococcal infection,and 20.0%（6/30） were due to PNS〕;64.8%（70/108） had stage 1 AKI〔60.0%（42/70） were caused by PNS,22.8%（16/70） were by glomerulonephritis due to acute streptococcal infection〕;25.0%（27/108） had stage 2 AKI〔37.0%（10/27） were caused by PNS,and 25.9%（7/27） were by glomerulonephritis due to acute streptococcal infection〕;10.2%（11/108） had stage 3 AKI〔36.3%（4/11） were caused by PNS,and 27.3% were by glomerulonephritis due to acute streptococcal infection〕.The overall response rate（RR） was 83.3%（90/108）.The RR in patients with stage 3 AKI was much lower than that in those with stage 1 or stage 2 AKI（P〈0.05）.The RR differed significantly between AKI children with massive proteinuria or hypoproteinemia or hypertension（P〈0.05）.Multivariate Logistic regression analysis indicated that massive proteinuria,hypoproteinemia,and hypertension were the factors affecting the prognosis of AKI in children（P〈0.05）.Conclusion AKI in children secondary to intrinsic renal diseases can be caused by many reasons,but it mainly by PNS and glomerulonephritis due to acute streptococcal infection.Infants,preschool-age children and school-age children are prone to AKI.Good prognosis can be achieved in most of children after active treatment,but it is affected by many factors such as massive proteinuria,hypoproteinemia,hypertension and so on.