感染性心内膜炎合并急性肾损伤的临床特点和手术预后分析

Clinical feature and post-operative prognosis of infective endocarditis patients with acute kidney injury

目的分析感染性心内膜炎(IE)合并急性肾损伤(AKI)的诊治和预后情况,评判手术治疗对预后的影响。方法回顾性分析北京协和医院2010年1月至2016年5月45例IE合并AKI患者的临床资料,其中包括8例肾脏病理组织学改变;将患者分为手术(22例)和非手术组(23例),比较两组的临床资料和预后。结果本组资料男女比2.46∶1,发病年龄(48.3±16.6)岁。35.6%有基础瓣膜疾病,先天性瓣膜疾病最常见。好发感染瓣膜依次为二尖瓣(46.7%)、主动脉瓣(28.9%)和人工瓣膜(8.9%)。常见的感染病原为链球菌(46.7%)和葡萄球菌(35.6%),感染病原中也可见部分少见及特殊类型。肾脏表现中,尿潜血和尿蛋白的比例分别为82.2%和64.4%;8例肾活检病理中,新月体肾炎3例,局灶增生性肾炎和系膜增生性肾炎各2例,急性间质性肾炎1例;免疫荧光最常见的形式是C3沉积。手术和非手术患者基线资料、手术存活率无显著差别,但手术组肾功能恢复显著优于非手术组(P<0.05),血清肌酐在术后7 d和30 d即较术前显著下降(P<0.05和P<0.01)。结论 IE的基础疾病和感染病原学较传统记载存在变化,IE导致肾实质损害时,新月体肾炎并非少见;适时手术有利于改善IE合并AKI患者的肾脏预后。

Objective To analyze the clinical features and prognosis of patients with infective endocarditis （IE） and acute kidney injury（AKI） , and to evaluate the effect of timely operation on prognosis of renal function. Methods Clinical data of 45 IE and AKI eases in Peking Union Medical College Hospital from January 2010 to May 2016 were retrospectively reviewed; among them 8 cases underwent renal biopsy and the pathologies were analyzed. Pa- tients were divided into Operation group （22 cases） and Non-operation group （23 cases）, the clinical data and prognosis were compared. Results The ratio of male to female was 2.46 ： 1 and the average age was 48.3±16.6. 35.6% of cases were found with basic valve diseases, the congenital valve diseases were the most common type. The most frequently infected valves were mitral valve （46.7%）, aortic valve （28.9%） and prosthetic valve （8.9%） ordinally. The most common pathogenic bacteria were streptococcus（46.7%） and staphylococcus （35.6%）. Some rare and special pathogen could also be found in these cases. In 8 cases underwent renal biopsy, 3 cases were diag- nosed as crescentic nephritis, 2 cases were diagnosed as focal proliferative glomerulone-phritis and mesangial prolif-erative glomerulonephritis respectively, 1 case was diagnosed as acute interstitial nephritis. C3 sedimentation was the most common phenomenon found in immunofluorescence. There was no significant difference between the base- line data of Operation and Non-operation groups, and neither was the survival rate. However, renal function recov- ered better in Operation group（P〈0. 05） ： the serum creatinine declined remarkably in 7 days（P〈0. 05） and 30 days（P〈0. 01 ）post operation, compared with the peak valve before operation. Conclusions The underline valve diseases and pathogen have been changed in IE as compared with traditional description. Crescentic nephritis is common tlon can in renal pathologic manifestation when parenchymal lesion is developed after the onset of IE. Timely opera- improve the renal prognosis in patients with IE and AKI.